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Question: Our ophthalmologist performed a technique to repair blepharoptosis by suspending the eyelid from the frontalis muscle above the eyelid. After the provider delivered the anesthetic, they placed a traction suture through the upper eyelid margin and clamped it inferiorly. They then made the necessary incisions in the eyelids and the brow. The physician created a sling from banked fascia, then used a fascia needle to thread the fascia between the incisions. They secured the fascia or suture material after achieving optimal eyelid height and contour and closed the incisions in layers.

Should we use 67901 or 67902 to document this procedure?

Wisconsin Subscriber

Answer: Blepharoptosis is a condition that causes the upper eyelid to droop either fully or partially over one or both pupils. It is usually resolved by surgery that attaches the eyelid to the frontalis muscle in the forehead, either with sutures or donor tissue.

The method of attachment is your clue to assigning the correct code for this procedure. If the ophthalmologist uses sutures — the procedure you describe — you’ll use 67901 (Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)). The key to documenting this procedure is the phrase “suture or other material” in the code description. In this procedure, a needle equipped with threadlike material is passed through incisions in the brow and eyelid, creating a sling to support the drooping eyelid. Possible suture materials include preserved and autogenous fascia lata (fascia tissue from the eyelid itself), #40 silicone bands, silicone rods, and prolene sutures.

But if the surgery requires the ophthalmologist to construct a sling made from tissue obtained from the patient’s thigh, you’ll use 67902 (… frontalis muscle technique with autologous fascial sling (includes obtaining fascia)). As this procedure code states obtaining the fascia is a part of the service, so you won’t be able to code for harvesting the fascia separately.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC