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Code This!

Scenario Week of September 06, 2012:
View Current Scenario

Assign the appropriate ICD-9-CM diagnosis and procedure codes as well as CPT for the following outpatient scenario:

Blepharoplasty and ptosis repair

Preoperative diagnosis: Bilateral ptosis
Procedure: Bilateral ptosis repair, bilateral blepharoplasty

Estimated blood loss: Trace
Anesthesia: Monitored anesthesia care
Complications: None

Description of procedure: This 57-year-old female patient presents for cosmetic repair of bilateral ptosis and bilateral blepharoplasty. Risks were discussed and informed consent obtained.

The patient was brought to the operating room and put in the supine position. After the administration of propofol, local anesthesia was administered by infiltration using 2% Lidocaine with epinephrine in the left periocular area. An incision was made using a #15 scalpel along the upper eyelid crease. The incision was carried down to the level of the levator aponeurosis with sharp and blunt dissection. Cautery was used as needed. The levator was carefully dissected from the underlying Mueller’s muscle. The tissue overlying the tarsal plate was dissected carefully away from the tarsal plate. In interrupted fashion, sutures were used to bring the levator aponeurosis in apposition to the midportion of the tarsal plate, accomplishing the lid elevation. A small ellipse was marked on the upper eyelid and this tissue excised. The skin was closed in running and interrupted fashion. Bacitracin ophthalmic ointment was applied. The procedure was then repeated on the right eye. The patient left the operating room in good condition, having tolerated the procedure well.

Code This! Assign the correct CPT and ICD-9-CM diagnosis and procedure codes.

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.

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