Description:
Phototherapeutic keratectomy involves the use of the excimer laser to treat visual impairment or irritative symptoms relating to diseases of the anterior cornea by sequentially ablating uniformly thin layers of corneal tissue. Phototherapeutic keratectomy may be performed in the office setting using topical anesthesia. Phototherapeutic keratectomy must be distinguished from photorefractive keratectomy, which involves the use of the excimer laser to correct refractive errors of the eye (i.e., myopia, astigmatism, hyperopia and presbyopia). Photorefractive keratectomy is addressed in a separate policy, No. 90302.

Essentially, phototherapeutic keratectomy (PTK) functions by removing anterior stromal opacities or eliminating elevated corneal lesions while maintaining a smooth corneal surface. Complications of PTK include refractive errors, most commonly hyperopia, corneal scarring and glare. The U.S. Food and Drug Administration (FDA) labeling for the excimer laser identifies the following ophthalmologic therapeutic indications:

• Superficial corneal dystrophies (including granular, lattice and Reis-Buckler's dystrophies)
• Epithelial basement membrane dystrophy, irregular corneal surfaces (secondary to Salzmann's degeneration, keratoconus nodules or other irregular surfaces)
• Corneal scars and opacities (i.e., post-traumatic, post-surgical, post-infectious and secondary to pathology).

Although not included in the FDA labeling, there has been interest in PTK as a treatment of recurrent corneal erosions in patients who have not responded to conservative therapy with patching, cycloplegia, topical antibiotics and lubricants.

When PTK is used to remove only the epithelial surface of the cornea, the alternative technology is mechanical superficial keratectomy, i.e., corneal scraping. When PTK is used to remove deeper layers of the cornea, i.e., extending into Bowman's layer, competing technologies include lamellar keratoplasty. In addition, candidates for PTK should have exhausted medical approaches. For example, recurrent corneal erosions can be treated conservatively with lubricants, patching, bandage contact lenses or anterior stromal punctures, while keratoconus can be treated with rigid contact lenses to correct the astigmatism.

Policy:

• Phototherapeutic keratectomy may be considered MEDICALLY NECESSARY when used as an alternative to a lamellar keratoplasty in the treatment of visual impairment or irritative symptoms related to corneal scars, opacities or dystrophies extending beyond the epithelial layer.
• Phototherapeutic keratectomy is considered NOT MEDICALLY NECESSARY when used as an alternative to a superficial mechanical keratectomy in treating patients with superficial corneal dystrophy, epithelial membrane dystrophy and irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules.
• INVESTIGATIONAL applications of phototherapeutic keratectomy include, but are not limited to, treatment of recurrent corneal erosions and infectious keratitis. 

Policy Guidelines:
There is no specific CPT code for PTK. CPT code 65400 (excision of lesion, cornea [keratectomy, lamellar, partial]) may be used. Superficial mechanical keratectomy may be coded by 65435 – 65436 (removal of corneal epithelium). CPT code 65710 describes a lamellar keratoplasty. There is a HCPCS code, S0812, that is specific for this procedure. 

The following ICD-9 and ICD-10 codes describe superficial corneal lesions; PTK for these conditions would be considered NOT MEDICALLY NECESSARY.  

371.51 Juvenile epithelial corneal dystrophy
371.52 Other anterior corneal dystrophy
371.53 Granular corneal dystrophy
371.54 Lattice corneal dystrophy
371.46 Nodular degeneration of cornea (i.e., Salzmann's nodular dystrophy)
371.6 Keratoconus code range 

ICD-10-CM

H1852 Epithelial (juvenile) corneal dystrophy
H1859 Other hereditary corneal dystrophies
H1853 Granular corneal dystrophy
H1854 Lattice corneal dystrophy
H18459 Nodular corneal degeneration, unspecified eye
H18609 Keratoconus, unspecified, unspecified eye
H18619 Keratoconus, stable, unspecified eye
H18629 Keratoconus, unstable, unspecified eye 

The following ICD-9 and ICD-10 codes describe corneal scars and opacities and nonepithelial lesions; PTK for these conditions may be considered MEDICALLY NECESSARY.  

371.0 Corneal scar and opacities code range
371.56 Stromal corneal dystrophy 

ICD-10-CM

H17.00 – H17.9
H18.00 – H18.069 

The following ICD-9 and ICD-10 codes describe recurrent corneal erosions and infectious keratitis, and PTK for these conditions is considered INVESTIGATIONAL.  

371.42 Recurrent corneal erosions
017.3 Tuberculosis of the eye
053.21 Herpes zoster keratoconjunctivitis
054.40-054.49 Ophthalmologic herpes simplex code range
055.71 Measles keratoconjunctivitis
077.1 Epidemic keratoconjunctivitis
090.3 Syphilitic interstitial keratitis
370.44 Keratitis or keratoconjunctivitis in exanthema 

ICD-10-CM