Ophthalmology and Optometry Coding Alert

Question: What is the correct code for a levator resection to repair blepharoptosis?

California Subscriber

Answer: It depends on the approach. Most often, the ophthalmologist will use an external approach, creating an incision in the fold of the upper eyelid through which he accesses the levator tendon. He then resects or advances the tendon to correct the eyelid's drooping. Report this approach with 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach).
 
Sometimes the ophthalmologist will need to approach the muscle internally, through the conjunctiva. If you have documented that the surgeon everted the eyelid (i.e., turned it inside-out) and resected the levator tendon through the conjunctiva, report 67903 (... [tarso] levator resection or advancement, internal approach).