Ophthalmology and Optometry Coding Alert

Reader Questions:

Decode This Blepharoptosis Scenario

Published on Wed Feb 16, 2022

Question: The ophthalmologist performed a technique to repair blepharoptosis by suspending the eyelid from the frontalis muscle above the eyelid. Prior to surgery, the physician confirmed the surgical site and marked the planned incisions with a pen. After anesthetic was delivered, the physician placed a traction suture through the upper eyelid margin and clamped it inferiorly. He then made the necessary incisions in the eyelids and the brow. The physician used banked fascia as a sling, using a fascia needle to thread the fascia between the incisions. He secured the fascia or suture material after achieving optimal eyelid height and contour, and closed the incisions in layers. How should we code this procedure?

Michigan Subscriber

Answer: Many of the blepharoptosis repair codes (67901-67908, Repair of blepharoptosis ...) describe procedures that seem almost identical. There are key differences, however, that will help you choose the correct code for the procedure your ophthalmologist performed.

For the procedure you describe, 67901 (Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)) is likely the most accurate code.

The key to this procedure is the phrase “suture or other material” in the code description. In this procedure, the ophthalmologist passes a needle equipped with threadlike material through incisions in the brow and eyelid, creating a sling to support the drooping eyelid. Possible suture materials include preserved and autogenous fascia lata, #40 silicone bands, silicone rods, and prolene sutures. Because your physician documented this technique, then 67901 is likely the most appropriate code for this situation.