Billing code 68525: Tear sac biopsyMedicare rate & RVUs in Illinois
Reports surgical sampling of lacrimal sac tissue for diagnostic evaluation when a lesion or abnormal tissue requires examination.
CMS doesn’t publish an office rate for 68525 in Illinois.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 68525 covers
An ophthalmologist, often an oculoplastic surgeon, samples tissue from the lacrimal sac for diagnostic evaluation. The sac is part of the tear-drainage system near the inner corner of the eye. Biopsy may be considered when abnormal tissue or a suspected lesion requires examination; the specimen is submitted for pathologic evaluation. The operative note should identify the sac as the tissue sampled and explain the clinical reason for biopsy.
Report this service for tissue sampling, rather than removal of the sac. Document the operative findings, biopsy site, and specimen obtained. CMS assigns a 0-day global period, so same-day preoperative and postoperative care is included. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and the others are subject to the standard multiple procedure reduction. For bilateral procedures, modifier 50 is paid at 150%. Assistant-at-surgery payment is restricted; co-surgeons require supporting documentation, and team surgery is not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 68525 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | Unavailable | $223.25 |
| East St. Louis | Unavailable | $214.58 |
| Rest Of Illinois | Unavailable | $208.80 |
| Suburban Chicago | Unavailable | $218.07 |
How the 68525 rate is calculated
Each of 68525’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 68525
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 4.31Practice expense 1.51Malpractice 0.36
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 68525
The CMS indicators that decide how 68525 is paid alongside other services.
CMS payment indicators · 68525
Tear sac biopsy
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 000 | Same-day global: pre- and post-op care on the day of the procedure is included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 1 | Bilateral with modifier 50 pays 150% of the fee schedule amount. |
| Assistant at surgery (80/81/82/AS) | 1 | Not paid (statutory restriction). |
| Co-surgeons (62) | 1 | Permitted with supporting documentation. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
What modifiers do to the payment
Modifier 50 · payment effect
With and without the modifier
68525 without 50 · national facility
$206.42
Tear sac biopsy
68525-50 · Bilateral: 150%
$309.63
Both sides on one line with modifier 50 are paid at 150% of the fee schedule amount (subject to multiple-procedure rules with other procedures).
68525 compared with similar codes
Compare codes
68525 vs 68520 vs 68510 vs 68530: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 68520Tear sac surgery
- 68525 samples sac tissue for diagnosis; 68520 is the code to consider when the tear sac is removed.
- 68510Lacrimal biopsy
- Both are biopsy procedures, but 68510 targets the lacrimal gland and 68525 targets the lacrimal sac.
- 68530Tear duct clearance
- 68530 concerns clearance of the tear duct; 68525 reports sampling tissue from the tear sac for diagnosis.
68525 billing questions
How is a sac biopsy different from removal of the tear sac?
Report 68525 when tissue is sampled for diagnosis. When the tear sac itself is removed, consider 68520 instead.
Can tear-sac biopsy be reported with a pathology service?
The biopsy reports the surgical tissue sampling. Any separately reported pathology service represents examination of the specimen, not the act of obtaining it.
What documentation supports 68525?
The operative note should identify the lacrimal sac as the sampled tissue, describe the reason for biopsy and the tissue obtained, and document relevant findings.
How does Medicare treat bilateral reporting?
CMS lists the procedure as bilateral; when both sides are treated, modifier 50 is paid at 150%.
What happens when another procedure is performed in the same session?
Under the standard multiple procedure reduction, the highest-valued procedure is paid in full and the other procedures are paid at 50%.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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