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Scenario Week of March 29, 2012:
View Current Scenario

Preoperative diagnosis: Bilateral ptosis of upper eyelids
Postoperative diagnosis: Same
Operation performed: Bilateral external levator resection
Anesthesia given: Local monitored anesthesia care
Estimated blood loss: Negligible
Complications: None

INDICATIONS: The patient is a healthy 59-year-old female with decreased vision bilaterally due to considerable ptosis with absence of lid crease and a levator function of 12 mm per side. The risks and benefits of the procedure were explained to the patient, and she consents to the procedure.

Local anesthesia was provided using a mixture of 50/50 2% Xylocaine with epinephrine and 0.75% Marcaine which was injected into the upper eyelids bilaterally. The patient was placed in the supine position, and prepped and draped in the customary manner. A marking pen was used to delineate the eyelid incisions. A #15 blade was used to cut through the skin along the fusiform section of tissue to be removed in the right eye. Using the fine-point Bovie electrocautery instrument hemostasis was obtained. Addressing the superior one-half of the fusiform section, a plane was dissected down to pre-aponeurotic fat and the levator aponeurosis was identified. It was noted to have significant atrophy and fatty infiltration.

The tarsus was identified by excising the fusiform section of orbicularis previously marked. A dissection plane through the orbicularis at the superior aspect of the tarsus was performed and this was advanced to the inferior margin of the tarsus. This plane was dissected laterally and temporally and nasally. Good hemostasis was achieved throughout the procedure. Next, double-armed 6-0 silk sutures on a TG-140 needle were used to pass through the superior aspect of the levator aponeurosis and through the tarsus. Fellow sutures were passed laterally and nasally to the centrally passed suture. The sutures were tightened to obtain the desired level of lid elevation and contour, then tied and cut.

The skin was closed using interrupted 6-0 Prolene sutures by incorporating skin, orbicularis, and levator aponeurosis on the inferior portion and then skin on the superior portion of this interrupted suture. A simple running suture was passed through skin, using a 6-0 Prolene suture. The same procedure was performed on the left eye.

The patient tolerated the procedure well and was returned to the recovery area in satisfactory condition.


ICD-9-CM Diagnosis Code
374.30 Ptosis of eyelid, unspecified

In this scenario, the surgeon did not document any of the other more specific types of eyelid ptosis such as that caused by a nerve or muscle disorder, resulting in the need to report the unspecified code.

CPT Procedure Code
67904-50 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach, bilateral

The surgeon specifically documents and describes a “Bilateral external levator resection” as the procedure performed. The use of modifier 50 Bilateral procedure, is warranted for this case as both eyes were operated on. Be sure to check with the individual payers regarding how they expect to see modifier 50 reported on the claim (e.g., one line or two). Use of the operating microscope (code 69990) is an inherently inclusive component of code 67904 and is not reported separately.

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