ICD-9-CM Code: 374.0 Entropion and trichiasis of eyelid
CPT Code: 15822-50 Blepharoplasty, upper eyelid – Bilateral procedure
Rationale: Ptosis of the upper eyelids is a lowering of the upper eyelid margin in relation to the upper limbus of the cornea beyond the normal 1-2 mm. When the ptotic lid covers enough of the upper limbus or pupil it may result in both functional and aesthetic deformities. Ptosis of the eyelid may be caused by a wide range of conditions including congenital ptosis, Lyme disease, myasthenia gravis, and trauma. However, the most common type of ptosis is due to aging. It is important to understand the procedure may not be covered by payers unless the ptosis results in a functional disturbance. Often, preapproval and extra documentation, including photographs, may be required to justify the medical need for the procedure.
Turn to the ICD-9-CM index under the main term “Ptosis” where subterm “eyelid” and the additional subterms “congenital,” “mechanical,” “myogenic,” and “paralytic” are listed. In this case, the physician has not indicated a specific type of ptosis. However, the surgeon does state the procedure was done for cosmetic reasons. Due to the exclusion of other types of ptosis, code 374.30 would be selected.
In the CPT index, the main term “Blepharoplasty” references 15820-15823. The descriptors for this range of codes indicate upper and lower eyelids and whether the patient is noted to have excessive herniation of the fat pad. In this case, code 15822 would be selected with modifier 50 to indicate both eyes were operated on. Check with the payer to see how it prefers modifiers be used on the CMS-1500 claim form.