What is the correct Current Procedural Terminology (CPT) code for a laser trabeculoplasty procedure in a patient with uncontrolled intraocular pressure?

CPT Code for Laser Trabeculoplasty

The correct CPT code for a laser trabeculoplasty procedure in a patient with uncontrolled intraocular pressure is 65855 (option C). 1

Procedure Identification and Coding Rationale

Laser trabeculoplasty (CPT 65855) is the appropriate code for this procedure based on the following considerations:

• The procedure involves using laser energy to target the trabecular meshwork to increase aqueous outflow and lower intraocular pressure 1
• The patient is undergoing her first treatment application, which aligns with the initial laser trabeculoplasty procedure
• The patient has uncontrolled intraocular pressure, which is the primary indication for this procedure 2

Differentiating from Other Codes

The other codes provided in the question represent different ophthalmic procedures:

• 65850: Trabeculotomy ab externo - an incisional surgical procedure, not a laser procedure
• 66170: Trabeculectomy ab externo - a filtering surgical procedure, more invasive than laser trabeculoplasty
• 66172: Trabeculectomy ab externo with scarring from previous ocular surgery or trauma - a more complex surgical procedure

Clinical Context

Laser trabeculoplasty is indicated in this patient because:

• She has uncontrolled intraocular pressure despite medical therapy 2
• The American Academy of Ophthalmology recommends laser trabeculoplasty as an appropriate treatment for patients with uncontrolled intraocular pressure 1
• The procedure can be performed using different laser types, including Argon laser trabeculoplasty (ALT) and Selective laser trabeculoplasty (SLT) 2

Expected Outcomes and Follow-up

• The patient will be monitored over the next three months to ensure normal inflammation subsides, which is consistent with the standard post-procedure care
• The patient may experience an IOP reduction of approximately 20-30% from baseline 1
• Follow-up examinations should be performed within 6 weeks of surgery or sooner if there is concern about IOP-related damage 1

Common Pitfalls and Considerations

• It's important to document pre-procedure and post-procedure IOP measurements (within 30 minutes to 2 hours after surgery) 1
• The patient should be monitored for potential complications such as temporary IOP spikes, which occur in 4.5-27% of cases 1
• The early cataract noted in the patient's history should be documented but does not affect the CPT code selection for the laser trabeculoplasty procedure

The evidence clearly supports using CPT code 65855 for this laser trabeculoplasty procedure in a patient with uncontrolled intraocular pressure.