Identify the Code for Eyelid Retraction Injections
Question: A patient presented with complaints of chronic bilateral upper lid cicatricial retraction with lagophthalmos. The ophthalmologist injected the patient’s upper eyelids with 5-fluorouracil into scar tissue on each eyelid. How would I report this procedure? Connecticut Subscriber Answer: Assign 11900 (Injection, intralesional; up to and including 7 lesions) to report the injections into the patient’s upper eyelids. Depending on your payer, you may also need to append modifiers LT (Left side) and RT (Right side) to 11900 to indicate the provider injected scar tissue on each eyelid. Upper eyelid cicatricial retraction is a type of eyelid retraction where the eyelid fails to fully lower when the patient looks down. This is known as lagophthalmos. The condition can develop as a result of scar formation in the eyelid, among other reasons. The 5-fluorouracil medication is reported with HCPCS Level II code J9190 (Injection, fluorouracil, 500 mg). Report 1 unit of J9190 and modifier JZ (Zero drug amount discarded/not administered to any patient) if a single-dose vial is used, but don’t append modifier JZ when the provider uses multidose vials. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
