CPT/HCPCS Codes -15823, 15822, 67900, 67924 Blepharoplasty

Procedure codes and Description

15822 BLEPHAROPLASTY, UPPER EYELID;

15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID

67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)

67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)

67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)

67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH

67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH

67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA)

67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)


67909 REDUCTION OF OVERCORRECTION OF PTOSIS


Coverage Indications, Limitations, and/or Medical Necessity

Introductory Definitions
Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process.

Blepharochalasis: excess skin associated with chronic recurrent eyelid edema that physically stretches the skin.

Blepharoptosis: drooping of the upper eyelid related to the position of the eyelid margin with respect to the visual axis

Pseudoptosis (“false ptosis”): For the purposes of this policy, the specific circumstance where the eyelid margin is in an appropriate anatomic position with respect to the visual axis but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin so as to become a “pseudo” lid margin. [Note: other causes of pseudoptosis are not the subject of this policy unless specifically referenced.]

Brow ptosis: drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid that may cause mechanical blepharoptosis and/or dermatochalasis

Blepharoplasty: removal of eyelid skin, fat, and or muscle

Blepharoptosis repair: restoring the eyelid margin to its normal anatomic position.

Brow ptosis repair: restoring the eyebrow tissues to their normal anatomic position.

Upper Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair (Brow Lift)

Blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic (i.e., to enhance appearance).

For the purposes of this policy, these surgeries (either individually or in the minimum combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. Published literature correlates this amount of field restriction with a Margin Reflex Distance (see below) of 2.0 mm or less.

This policy is not intended to cover reconstructive surgery, which is done to improve function or approximate a normal appearance in circumstances of congenital defects, developmental abnormalities, trauma, infection, tumors, or diseases not specifically referenced as included. Examples of such surgeries are (but not limited to):

ectropion or entropion repairs.

repairs to address ocular exposure.

repairs to address difficulty fitting an ocular prosthesis

primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is debilitating for which all other treatments have failed or are contraindicated.

prompt repair of an accidental injury


Note, however, the fact that this policy excludes reconstructive surgery does not relieve the physician of the obligation to document in the medical record reasonable evidence defending the medical necessity of a given procedure, including but not limited to an appropriate patient complaint that would impact their ability to perform tasks of daily living (or, in the absence of a specific complaint, a statement that the repair is needed to prevent anticipated future damage to ocular structures), an appropriate physical exam delineating the anatomical issues to be addressed, appropriate supplemental testing, appropriate photographic documentation clearly demonstrating to a qualified third-party the anatomical issues to be addressed, and appropriate operative notes and consents.

Lower Eyelid Blepharoplasty

Lower eyelid blepharoplasty is almost never functional in nature and is considered a non-covered procedure under this policy. Appeals to this statement may be considered on a case-by-case basis.

Coverage when a Noncovered Procedure is Performed with a Covered Procedure

When a noncovered cosmetic surgical procedure is performed in the same operative session as a covered surgical procedure, benefits will be provided for the covered procedure only. For example, if dermatochalasis would be resolved sufficiently by brow ptosis repair alone, an upper lid blepharoplasty in addition would be considered cosmetic. Similarly, if a visual field deficit would be resolved sufficiently by upper lid blepharoplasty alone (for tissue hanging over the lid margin), a blepharoptosis repair in addition would be considered cosmetic.

Indications

Blepharoplasty procedures and repair of blepharoptosis are covered when performed for the following functional indications. All other uses would be considered cosmetic.

Lower lid blepharoplasty (CPT 15820 and 15821) is considered as medically necessary when documentation:

supports horizontal lower eyelid laxity of medial and lateral canthus resulting in dacryostenosis or infection; or

supports significant lower eyelid edema.

reveals that glasses rest upon the lower eyelid tissues and cause lower eyelid ectropion as a result of the weight of the glasses and weight of the tissue.

Upper Eyelid Blepharoplasty (CPT 15822 & 15823) is considered medically necessary when:

Clinical notes and visual field testing support a decrease in peripheral vision and/or upper field vision; and

Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations; and

Documentation of visual fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

Repair of Brow Ptosis (CPT 67900) and Blepharoptosis (67901 & 67902) are considered medically necessary for the following functional indications:

Clinical notes and visual field testing that support a decrease in peripheral vision and/or upper field vision; and

Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations; and

Documentation of Visual Fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

Ptosis Repair (CPT 67903-67908) is considered as medically necessary when:

Documentation supports a treatable cause has been excluded; and

Pre-operative photos reveal the ptotic lid covering one-forth of the pupil or 1-2mm above the midline of the pupil; and

Documentation of Visual Fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia or developmental errors. The following are terms used to describe conditions that may necessitate blepharoplasty:
  • Dermatochalasis: Excessive skin of the upper eyelid, usually the result of the aging process with loss of elasticity.
  • Blepharochalasis: Excessive skin of the eyelid, usually associated with the disease process of chronic blepharoedema, which physically stretches and thins the skin.
  • Blepharoptosis: Drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and visual axis.
  • Pseudoptosis: “False ptosis” – The eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis; however, the amount of excessive skin is so great it overhangs the eyelid margin and creates its own ptosis.
  • Ptosis: Drooping of the upper eyelid.
Blepharoplasty procedures and repair of blepharoptosis and anesthesia for these procedures are covered only when performed as functional/reconstructive corrective surgery and when:
  • Documented ptosis, pseudoptosis or dermatochalasis is present.
  • There is interference with vision or visual field.
  • There is difficulty reading due to upper eyelid drooping.
  • The patient is looking through the eyelashes or seeing the upper eyelid skin.
  • There is chronic blepharitis.
  • There is visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis.
  • There is symptomatic redundant skin weighing down on upper lashes.
  • There is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin.
  • There are prosthesis difficulties in an anophthalmic socket.
Medicare expects that the above-noted conditions will be appropriately documented and able to be visualized in the supportive photographs or videos maintained as part of the patient record.
 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Revenue codes have not been identified for these procedures, as they can be performed in a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360) or clinic (0510). Providers should report these HCPCS codes under the revenue center where they were performed.
CPT/HCPCS Codes



15822©  Revision of upper eyelid
15823© Revision of upper eyelid
67900© Repair brow defect
67901© Repair eyelid defect
67902© Repair eyelid defect
67903© Repair eyelid defect
67904© Repair eyelid defect
67906© Repair eyelid defect
67908© Repair eyelid defect
67916© Repair eyelid defect
67917© Repair eyelid defect
67923© Repair eyelid defect
67924© Repair eyelid defect




ICD-10 CODE DESCRIPTION

H02.30 - H02.36 - Opens in a new window Blepharochalasis unspecified eye, unspecified eyelid - Blepharochalasis left eye, unspecified eyelid

H02.401 - H02.403 - Opens in a new window Unspecified ptosis of right eyelid - Unspecified ptosis of bilateral eyelids

H02.409 Unspecified ptosis of unspecified eyelid

H02.411 - H02.413 - Opens in a new window Mechanical ptosis of right eyelid - Mechanical ptosis of bilateral eyelids

H02.419 Mechanical ptosis of unspecified eyelid

H02.421 - H02.423 - Opens in a new window Myogenic ptosis of right eyelid - Myogenic ptosis of bilateral eyelids

H02.429 Myogenic ptosis of unspecified eyelid

H02.431 - H02.433 - Opens in a new window Paralytic ptosis of right eyelid - Paralytic ptosis of bilateral eyelids

H02.439 Paralytic ptosis unspecified eyelid

H02.831 - H02.836 - Opens in a new window Dermatochalasis of right upper eyelid - Dermatochalasis of left eye, unspecified eyelid

H02.839 Dermatochalasis of unspecified eye, unspecified eyelid

H04.551 - H04.553 - Opens in a new window Acquired stenosis of right nasolacrimal duct - Acquired stenosis of bilateral nasolacrimal duct

H04.559 Acquired stenosis of unspecified nasolacrimal duct

L85.9* Epidermal thickening, unspecified

L87.9* Transepidermal elimination disorder, unspecified

L90.9* Atrophic disorder of skin, unspecified

L91.9* Hypertrophic disorder of the skin, unspecified

L94.9* Localized connective tissue disorder, unspecified

Q10.0 Congenital ptosis

Z44.20 - Z44.22 - Opens in a new window Encounter for fitting and adjustment of artificial eye, unspecified - Encounter for fitting and adjustment of artificial left eye


ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67916, 67917, 67923 and 67924:
Covered for:
368.40
Visual field defect, unspecified
373.4–373.6
Inflammation of eyelids
374.00–374.05
Entropion and trichiasis of eyelid
374.10–374.14
Ectropion
374.30–374.34
Ptosis of eyelid
374.51
Xanthelasma
374.56
Other degenerative disorders of skin affecting eyelid
374.87
Dermatochalasis
375.15
Tear film insufficiency, unspecified
701.8
Other specified hypertrophic and atrophic condition of skin
728.4
Laxity of ligament
743.61–743.62
Congenital anomalies of eyelids
V52.2
Artificial eye

Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Documentation should consist of the following:
  • History and physical.
  • Operative report.
  • Photographs/video.
Note: When photographs, slides or videos are taken, they must be frontal, canthus-to-canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudolid margin. The photographs, slides or videos must be of sufficient clarity to show a light reflex on the cornea. If redundant skin coexists with true lid ptosis, additional photographs, slides or videos may be taken with the upper lid skin retracted to show the actual position of the true lid margin (needed if both codes 15822© blepharoplasty and15823© blepharoplasty; upper eyelid with excessive skin weighing down lid are required and planned in addition to codes 67901-67908). Oblique views are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.
The following should be supported through photographs, slides or videos, which must be maintained within the patient’s medical records:
  • Visual fields recorded to demonstrate an absolute superior defect to within 15 degrees of fixation.
  • Upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket.
  • Essential blepharospasm or hemifacial spasm.
  • Significant ptosis in the downgaze reading position.
Note: If both a blepharoplasty and a brow ptosis repair are planned, both must be individually documented. This may require two sets of photographs, slides or videos showing the effect of drooping of redundant skin (and its correction by taping) and the actual presence of blepharoptosis. Photographs, slides or videos do not need to be submitted with the claim, but should remain part of the patient’s medical record and available to Medicare upon request.

Documentation Requirements

Reasonably complete information fulfilling the criteria in Section A (Patient Complaints and Physical Signs), and Section B (Photographs) as delineated below must be adequately documented in the patient’s medical records to demonstrate the reasonableness and necessity of the procedure(s) performed.

In general and where applicable, clinical notes, and physical findings rather than formal visual field testing, should support a decrease in the superior field of vision and/or peripheral vision. While they may be performed to demonstrate to the patient (if needed) the potential for improvement, or if required by the prevailing standard of care, this policy does not consider the visual field testing in documenting a procedure as reasonable and necessary. Exceptions may be considered on appeal (see below).

If two (or more) surgeries are planned, each must be individually documented. This may (sometimes, but not necessarily) require multiple sets of photographs.

The medical record should also clearly indicate a statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that the surgery will significantly improve functional status of the patient.

When requested documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, (i.e., illegible or incomplete) such services will be denied as not reasonable and necessary.

Section A. Patient Complaints and Physical Signs

A functional deficit or disturbance secondary to eyelid and/or brow abnormalities must be documented, such as interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or driving).

In addition, the documentation should show that the eye being considered for surgery has physical signs consistent with the functional deficit or abnormality.

For Blepharoptosis Repair

A margin reflex distance (MRD sometimes referred to as MRD1)) of 2.0 mm or less. The MRD is a measurement from the corneal light reflex to the upper eyelid margin (NOT any overhanging skin
that may be present causing pseudoptosis) with the brows relaxed, and

If applicable, the presence of Herring's effect (related to equal innervation to both upper eyelids) defending bilateral surgery when only the more ptotic eye clearly meets the MRD criteria (i.e., if lifting the more ptotic lid with tape or by instillation of phenylephrine drops into the superior fornix causes the less ptotic lid to drop downward and meet the strict criteria, the less ptotic lid is also a candidate for surgical correction.


For Upper Blepharoplasty and/or Brow Ptosis Repair:

Redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the “pseudo” margin produces a central "pseudo-MRD" of 2.0 mm or less, or

Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in corresponding gaze.


In the expected to be rare circumstance where a patient would fail the MRD criterion for a given surgery but the provider feels that visual field testing would, despite that fact, support performance of surgery for a functional reason, this can be considered on appeal.

If an anatomic abnormality of the eye (such as an eccentric or elongated pupil) makes the MRD either difficult to establish or meaningless for this purpose, it is expected the surgeon will include a statement outlining his or her rationale that an equivalent standard has been met.

Section B Photographs

Photographs are required to support upper eyelid surgery as reasonable and necessary.

The “physical signs” documented in Section A must be clearly represented in photographs of the structures of interest and the photographs must be of good quality and of sufficient size and detail as to make those structures easily recognizable.

The patient’s head and the camera must be in parallel planes, not tilted so as not to distort the appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent measurement of a MRD).

Unless medial/lateral gaze is required to demonstrate a specific deficit, photos should be with gaze in the primary position, looking straight ahead.

Oblique photos are only necessary if needed to better demonstrate a finding not clearly shown by other requested photos.

Digital or film photographs are acceptable, and may be submitted electronically where possible. Photographs must be identified with the beneficiary’s name and the date. 

For Blepharoptosis Repair (CPT 67901 & 67902)
Photographs of both eyelids in the frontal (straight-ahead) position should demonstrate the MRD outlined in Section A. If the eyelid obstructs the pupil, there is a clear-cut indication for surgery. (For reference, the colored part of the eye is about 11 mm in diameter, so the distance between the light reflex and the lid would need to be about one fifth that distance or less for the MRD to be 2.0 mm or less.)

In the special case of documenting the need for bilateral surgery because of Herring’s law, two photos are needed:One showing both eyes of the patient at rest demonstrating the above MRD criterion in the more ptotic eye, and another showing both eyes of the patient with the more ptotic eyelid raised to a height restoring a normal visual field, resulting in increased ptosis (meeting the above MRD standard) in the less ptotic eye.


NOTE: Reviewers will assume the accepted average of 11 mm of corneal diameter to assess measurements in photographs. If a patient’s corneal diameter deviates from this by more than 0.5 mm, this should be clearly documented in the record so appropriate adjustments can be made. . Alternatively, an accurate millimeter rule can be taped along the brow, on the cheek, or elsewhere in the photo (approximately in the corneal plane) to facilitate such measurements.


For Upper Lid Blepharoplasty (CPT 15822 & 15823)

Photographs of the affected eyelid(s) in both frontal (straight ahead) and lateral (from the side) positions demonstrate the physical signs in Section A. Oblique photos are only necessary if needed to better demonstrate a finding not clearly shown by frontal and lateral photos.

For Brow Ptosis Repair (CPT 67900)

One frontal (straight ahead) photograph should document drooping of a brow or brows and the appropriate other criteria in Section A. If the goal of the procedure is improvement of dermatochalasis, a second photograph should document such improvement by manual elevation of brow(s). If a single frontal photograph that includes the brow(s) would render other structures too small to evaluate, additional (overlapping to the degree possible) photos should be taken of needed structures to ensure all required criteria can be reasonably demonstrated and evaluated.



NOTE: If both a blepharoplasty and a ptosis repair are planned, both must be individually documented. This may (sometimes, but not necessarily) require two sets of photographs: showing a pseudo-MRD of 2.0 mm or less secondary to the redundant skin (and its correction by taping), AND an MRD of 2.0 mm or less secondary to the blepharoptosis. 

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