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Scenario Week of December 13, 2013:
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Assign the appropriate ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes for hospital ambulatory surgery.

PREOPERATIVE DIAGNOSIS: Bilateral upper eyelid lateral levator aponeurotic ptosis due to senescence, bilateral upper eyelid functional dermatochalasis.

POSTOPERATIVE DIAGNOSIS: Bilateral upper eyelid lateral levator aponeurotic ptosis due to senescence, bilateral upper eyelid functional dermatochalasis.

OPERATIONS PERFORMED: Bilateral blepharoptosis repair by external levator resection, bilateral blepharoplasty.

ANESTHESIA GIVEN: Local monitored anesthesia care.




INDICATIONS FOR PROCEDURE: The patient is a 61-year-old female who presents with a complaint of constricted vision in both eyes secondary to drooping eyelids restricting reading and driving. On previous office exam, the patient was noted to have a severe ptosis with absence of lid crease and a poor levator function on both sides in addition to excess and redundant eyelid skin with edema. After discussing these findings with the patient and obtaining visual fields, taped and untaped, and confirming that a significant functional superior field defect was present in both eyes and obtaining clinical photographs, the patient agreed to have the above-named procedure performed after explanation of the risks and benefits.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operative area and was prepped and draped in the usual sterile fashion following adequate anesthesia obtained utilizing a mixture of 50/50 2% Xylocaine with epinephrine and 0.75% Marcaine. Prior to this, the eyelid region to be resected was identified and marked with a marking pen. With the patient in the supine position, a #15 blade was then used to cut through skin along the fusiform section of the eyelid tissue to be removed in the right eye.

Blepharoplasty was performed. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.

The previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.

The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver.

Next, blepharoptosis repair was performed. Good hemostasis was obtained utilizing the fine-point Bovie electrocautery instrument. 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 fatty infiltration and significant atrophy. At this point, 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. A good hemostasis was again obtained throughout the procedure.

At this point, double-armed 6-0 silk sutures on a TG-140 needle were then utilized to pass through the superior aspect of the levator aponeurosis and then this was passed through the tarsus. The fellow sutures were passed laterally and nasally to the centrally passed suture. At this point, the sutures were tightened and the desired level of lid elevation and contour were obtained. These sutures were then tied permanently and cut.

The lateral aspect of the upper eyelid incision was then closed utilizing 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 then passed through skin, utilizing a 6-0 Prolene suture.

The same procedure was performed for the patient on the fellow eye; levator resection and removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis was obtained on the upper lid areas.

At the end of the operation, the patient’s vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, and no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally. It should be noted that the patient received 12 mg of Decadron intravenously on-call in the OR as well as 1 gram of Kefzol intravenously in the OR on-call.

The patient tolerated the procedure well without complications and returned to the recovery area in stable condition.

Please assign the correct ICD-9-CM and ICD-10-CM/PCS codes for the procedure above.

Coding Answers:

ICD-9-CM Diagnosis Codes
374.30 Unspecified ptosis of eyelid
374.87 Dermatochalasis
368.44 Other localized visual field defect

Eyelid ptosis, i.e., blepharoptosis, involves dysfunction of the levator (aponeurosis) palpebrae superiorus muscle or Mueller’s muscle or nerve innervation (CN III). Its function is to elevate the eyelid. When the ptosis is due to a disorder of the muscle itself, the poor levator function is considered intrinsic. When age-related, it is acquired (aponeurotic), and is the most common cause of acquired ptosis. It obstructs the superior field of vision. In this example, since it is intrinsic, due to age and not due to myogenic pathology, report unspecified ptosis of eyelid, 374.30. Dematochalasis (blepharochalasis) is redundant, excess skin and (herniated) fat which either weighs down the upper eyelid causing obstruction of the superior or peripheral visual field or results in herniated fat pad of the lower eyelid. It is due to sun damage to the skin and age-related degeneration affecting elasticity and muscle support and is reported as 374.87. When either of these conditions is functional and causing visual deficits, the documentation must support medical necessity to justify the corrective/reconstructive surgery is not cosmetic (RAC issue). Addition of the code for the type of visual field defect, 368.44, would identify negative consequences of these defects.

ICD-9-CM Procedure Codes
08.33 Repair of blepharoptosis by resection or advancement of levator muscle or aponeurosis
08.87 Upper eyelid rhytidectomy
08.33 Repair of blepharoptosis by resection or advancement of levator muscle or aponeurosis
08.87 Upper eyelid rhytidectomy

Blepharoplasty to repair ptosis by levator resection is indexed as “Repair, blepharoptosis, levator muscle technique, with resection or advancement, 08.33.” Report this code twice to indicate it was bilateral. Blepharoplasty of the upper eyelid by means of excessive skin and fat excision is indexed as “Rhytidectomy, eyelid, upper, 08.87.” Report twice for bilateral.

CPT Procedure Codes
67904-50 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach, bilateral
15823-59-50 Blepharoplasty, upper eyelid; with excessive skin weighting down lid, distinct procedural service, bilateral

The CPT index indicates “Blepharoptosis, repair, tarso levator resection/advancement, external approach” is 67904 which will be sequenced first as it has a higher APC level. In assigning the correct codes for blepharoplasties, it is essential to distinguish the nature of the procedure: is it to the muscle or to the skin/fat only of the eyelid? Append modifier 50 as this was bilateral; always check with payers for their acceptance of modifiers. Removal of excess/redundant skin and herniated fat is not inherent in repair of eyelid ptosis. Also, the site of the blepharoplasty for dermatochalasis is anatomically skin which is not the same anatomical site as repair of ptosis. Report a blepharoplasty of the upper eyelid with excessive skin weighting down the lid with 15823. When 67904 and 15823 are reported together, a CCI edit notes the need for an appropriate modifier. In this case, append modifier 59 followed by modifier 50. Note that reporting these codes is appropriate; specific payers may not reimburse 15823, but that does not preclude reporting both when performed. Coverage and payment policies are governed by each payer.

ICD-10-CM Diagnosis Codes
H02.403 Unspecified ptosis of bilateral eyelids
H02.34 Blepharochalasis, left upper eyelid
H02.31 Blepharochalasis, right upper eyelid
H53.453 Other localized visual field defect, bilateral

The alphabetic index shows “Blepharoptosis (noncongenital)” is found in section H02.40, and the completed code is H02.403 for unspecified ptosis, bilateral eyelids. When reporting blepharochalasis, the laterality and the eyelid are identified by the 5th character; H02.34 left upper eyelid and H02.31 right upper eyelid.

ICD-10-PCS Procedure codes
08SN0ZZ Reposition upper eyelid, right, open
080N0ZZ Alteration upper eyelid, right, open
08SP0ZZ Reposition lower eyelid, left, open
080P0ZZ Alteration upper eyelid, left, open

Eyelid ptosis repair with levator resection would be performed by the root operation “reposition” of the body part “eyelid” to identify the objective of the procedure to move the eyelid to its normal position. The 4th character identifies the body parts of upper eyelid and lower eyelid as well as the laterality and the approach (open) without a device or qualifier: 08SN0ZZ right and 08SP0ZZ left. Blepharoplasty for dermatochalasis with removal of skin and fat is reported by the root operation “alteration” because it is to modify the natural anatomic structure of a body part without affecting its function. The 4th character for the body part is upper eyelid right and upper left, with open approach, no device and no qualifier: 080N0ZZ, 080P0ZZ.

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