CPT code 65426 – Excision of pterygium with graft

Key Takeaways

CPT code 65426 covers pterygium excision with conjunctival graft; code 65420 covers excision without graft and reimburses at a lower rate

Laterality modifiers LT and RT are required for every claim; modifier 50 for bilateral same-session procedures must be verified against current MPFS bilateral surgery indicator

V2790 (amniotic membrane supply) is typically denied when billed with 65426 and 65780 on the same claim per NCCI bundling edits

Pabau’s claims management software tracks modifier rules, global period billing, and denial reasons across ophthalmology procedure codes

CPT code 65426: descriptor and quick-reference data

CPT code 65426 describes “Excision or transposition of pterygium; with graft.” The American Medical Association (AMA) maintains this code within the Surgery/Eye and Ocular Adnexa section of the CPT code set. It is a five-digit numeric code with a 90-day global surgery period assigned under the Medicare Physician Fee Schedule (MPFS). For a structured overview of how it is used in ophthalmology CPT procedure code billing, the table below covers the key reference data.

What does CPT code 65426 cover?

CPT code 65426 covers the surgical excision or transposition of a pterygium combined with the placement of a conjunctival graft to resurface the exposed sclera. The graft step is what separates this code from 65420 and is the single most important element to document in the operative note.

The procedure, as described in clinical guidance from the AMA coding resources, encompasses three operative stages performed in one surgical session:

• Separation and excision: The pterygium is dissected free from the underlying corneal epithelium and underlying sclera, then fully excised.
• Scleral preparation: The bare scleral bed is cleaned and prepared to receive the graft.
• Graft placement: A conjunctival autograft (typically harvested from the superior bulbar conjunctiva of the same eye) or an amniotic membrane graft is sutured or glued into position to cover the defect.

What is NOT included: CPT code 65426 does not bundle the supply of an amniotic membrane product (V2790). Separate billing of V2790 is payer-dependent and frequently denied when 65780 appears on the same claim. Anesthesia is billed separately by the anesthesiologist.

CPT code 65426 vs. 65420: key differences

CPT code 65426 reimburses at a higher rate than 65420 because the graft step adds operative complexity and time. Choosing the wrong code is both an undercoding risk (if a graft was placed but 65420 is reported) and an overcoding risk (if no graft was used but 65426 is reported).

Adjacent and commonly confused codes: 65778, 65780, and V2790

Three codes regularly appear alongside CPT code 65426 on claims, and each carries its own bundling risk. Understanding when they can and cannot be billed together prevents the most common denial patterns in pterygium surgery billing. For broader context on surgical procedure CPT billing across ophthalmic specialties, the NCCI Policy Manual governs the bundling logic here.

The V2790 problem: According to AAPC (American Academy of Professional Coders) forum consensus, payers routinely deny V2790 when it appears on the same claim as 65426 and 65780. The payer logic is that the amniotic membrane supply is bundled into the procedure. Some Medicare Administrative Contractors (MACs) allow separate billing of V2790 under specific circumstances; verify against the applicable Local Coverage Determination (LCD) before submitting.

ICD-10 diagnosis codes for pterygium excision with graft billing

Every CPT code 65426 claim requires an ICD-10-CM diagnosis code that establishes medical necessity. The primary pterygium codes fall within category H11, which covers conjunctival degenerations and deposits. Using an unspecified or incorrect laterality code when a specific eye was operated on is a common documentation oversight that can trigger a medical necessity denial.

Confirm all H11.xx codes against the current CMS ICD-10-CM tabular list before use. For reference on ICD-10 diagnosis code pairing principles with CPT surgical codes, laterality specificity is consistently the deciding factor in medical necessity reviews across specialties.

Modifiers for CPT code 65426

CPT code 65426 is a lateralized procedure, meaning a modifier identifying which eye was operated on is required on every claim. Submitting without a laterality modifier is one of the most common technical denials in ophthalmology billing.

Bilateral pterygium: can CPT 65426 be reported twice?

Bilateral pterygium excision with graft can be reported for both eyes when performed in the same surgical session, but the billing method depends on the Medicare bilateral surgery indicator assigned to 65426 in the current MPFS. Verify this indicator before submitting. Two claims with separate dates carry LT on one and RT on the other.

Same-session bilateral claims may use modifier 50 or two line items with LT/RT, depending on payer preference. Review applicable CPT code modifier documentation rules and your MAC’s billing guidelines before submitting a bilateral claim for this procedure.

Medicare reimbursement for CPT code 65426

Medicare reimbursement for CPT code 65426 is calculated using the relative value units (RVUs) published in the annual CMS Medicare Physician Fee Schedule. The national unadjusted rate reflects work RVU, practice expense RVU, and malpractice RVU multiplied by the annual conversion factor, then adjusted by a Geographic Practice Cost Index (GPCI) for the practice location.

Always verify current rates directly on the CMS MPFS lookup tool, as rates change with each annual rulemaking cycle. The non-facility rate (office or ASC) generally exceeds the facility rate (hospital outpatient department). Submitting claims through electronic claims via Claim.MD helps validate RVU-based fee schedule calculations and route claims to the correct payer adjudication pathway before submission.

Commercial payer rates for CPT code 65426, including United Healthcare (UHC), are contractual and geography-dependent. No single authoritative rate applies across all contracts. Use your executed fee schedule or call the payer’s provider relations line for the applicable contracted amount. Also use the electronic remittance advice (ERA/835) from prior claims to benchmark expected reimbursement for your practice location.

Global period and post-operative billing for CPT 65426

The global period for CPT code 65426 is 90 days under the Medicare Physician Fee Schedule, beginning the day after the surgery date. During this period, routine post-operative services are bundled into the surgical payment and cannot be billed separately. Solid grounding in medical billing fundamentals helps staff distinguish which post-op visits are included and which qualify for separate billing.

• Included in the global package: routine post-operative visits related to normal recovery, suture removal, and follow-up slit-lamp exams for the operated eye.
• Separately billable (with modifier): a new, unrelated diagnosis evaluated during the global period (use modifier 24); a complication requiring a return to the OR (use modifier 78); a completely unrelated surgical procedure (use modifier 79).
• Separately billable without modifier: services for the fellow eye that are unrelated to the pterygium surgery, clearly documented as a distinct encounter.

Verify the current global days indicator against the MPFS file published by CMS each year. Some procedure codes have been reassigned from 90-day to 10-day global periods under CMS reform efforts, and relying on an outdated value risks incorrect billing.

Documentation requirements for CPT code 65426

The operative note for CPT code 65426 must document the graft explicitly. Payers reviewing a claim for this procedure will look for evidence that the higher-complexity graft technique was actually performed. Good superbill documentation practices and a complete operative record protect against both audits and automatic claim downcoding to 65420.

The operative note should include all of the following to withstand payer audit, per guidance from the American Academy of Ophthalmology (AAO):

• Laterality: Explicitly state which eye (right, left, or both) was operated on.
• Indication / medical necessity: Document the clinical indication for surgery (visual obstruction, progression, recurrence, discomfort) referencing the pterygium’s location relative to the visual axis.
• Excision description: Note the extent of pterygium excision, including separation from the underlying sclera and corneal surface.
• Graft type: Specify whether a conjunctival autograft, allograft, or amniotic membrane graft was used.
• Harvest site: For autografts, document the harvest location (e.g., superior bulbar conjunctiva of the same or fellow eye).
• Fixation method: State whether the graft was sutured, fibrin glued, or secured by another method.
• Complications: Note any intraoperative findings even if no complications occurred.

Reviewing prior operative notes with your operative documentation standards framework helps identify gaps before claims are submitted. Missing a single element (most often the graft type or harvest site) is the direct path to a medical records request and potential claim reduction.

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Common denial reasons for CPT code 65426 and how to appeal

CPT code 65426 has a predictable denial profile. Most rejections fall into five categories, each with a corresponding appeal strategy. Strong denial management workflows catch these before submission rather than after payment delay.

V2790 and 65426: bundling issues explained

The V2790 denial pattern is the most complex on this code. V2790 is an HCPCS supply code for the amniotic membrane itself, not the surgical placement procedure. When a surgeon places an amniotic membrane graft during pterygium excision and bills 65426 plus 65780 (the surgical placement code), payers view V2790 as bundled into the procedural payment.

Some MACs do allow V2790 as a separately billable supply when the amniotic membrane is used in a specific clinical context and 65780 is not on the same claim. The operative note must document the product name, lot number, and clinical justification. Check the applicable MAC’s LCD for pterygium or ocular surface reconstruction before billing V2790 on any claim that also includes 65426.

Using claims management software with built-in NCCI edit checking flags these bundling conflicts before the claim leaves the practice, reducing the denial-to-rework cycle significantly. The clean claim submission process for ophthalmology billing should include a pre-submission NCCI check as a standard step.

Conclusion

CPT code 65426 is a straightforward code to use correctly but an easy one to bill incorrectly. The graft must be documented in the operative note, the laterality modifier must be on the claim line, and the V2790/65780 bundling rules must be checked against the MAC’s LCD before submission. Miss any of these and the claim either denies outright or gets downcoded to 65420.

Pabau’s claims management software helps ophthalmology and dermatology and specialty clinic billing teams track modifier rules, global period status, and NCCI bundling conflicts across surgical procedure codes.

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