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Eyelid blepharoptosis and brow ptosis
******Coding Clinic, Second Quarter 1996 Page: 11 Effective with discharges: May 1, 1996
A 66-year-old female is admitted for surgical treatment of bilateral eyelid blepharoptosis and severe right brow ptosis. The patient presents with a history of pruritus of both upper eyelids, severe ptosis, and visual impairment. A visual field study confirmed the presence of visual field loss in the superior and superolateral visual fields. She also has marked ptosis of the right eyebrow with the right eyebrow displaced below the super orbital rim. The patient's right eyebrow was elevated to a more anatomical position and a bilateral upper blepharoplasty was performed. What are the appropriate diagnosis and procedure codes for this admission?
Assign code 374.30, Ptosis of eyelid, unspecified, for the bilateral eyelid blepharoptosis. Assign code 08.87, Upper eyelid rhytidectomy, for the brow lift, and code 08.70, Reconstruction of eyelid, not otherwise specified, may be assigned twice for the bilateral blepharoplasties.
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Anna Weaver, CPC, CPMA, CEMC