LCD Reference Article Billing and Coding Article

Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift

A56908

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56908
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift
Article Type
Billing and Coding
Original Effective Date
08/29/2019
Revision Effective Date
12/28/2023
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the social Security Act section 1833 (e). This section prohibits Medicare Payment for any claim that lacks the necessary information to process the claim.

Title XVIII 0f the Social Security Act section 1862 (a)(10). This section excludes cosmetic surgery, except as required to repair an accidental injury or for the improvement of the function of a malformed body member.

CR 10236 – October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS), 5. Upper Eyelid Blepharoplasty and Blepharoptosis Repair.

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD.

  1. List the appropriate CPT code for the procedure performed; include any appropriate modifiers.

  2. Physicians’ services and diagnostic tests must be submitted with a diagnosis code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise diagnosis code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the digit sub-classification for the diagnosis category. The diagnosis code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the diagnosis code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury resulting in a functional anomaly of the upper eyelids a cosmetic diagnosis should be reported, and payment will be denied.

  3. The Medicare global surgery and CCI rules apply to these eyelid surgeries.

  4. If bilateral reconstruction is done on the same day, report one line of service using the “50” modifier or report two lines of service with the RT and LT modifiers.

  5. If a patient wishes to have a blepharoplasty or brow lift for cosmetic purposes:
    1. The physician should explain to the patient, in advance, that Medicare will not cover cosmetic eyelid or brow surgery and that the beneficiary will be liable for the cost of the service. Charges should be clearly stated. A claim for cosmetic services does not need to be submitted to the Medicare contractor, unless the patient requests that the claim be submitted on his/her behalf.

    2. When the patient requests the claim for cosmetic services be submitted on his/her behalf, the services should be reported with modifier GY (items or services statutorily excluded or does not meet the definition of any Medicare benefit) and diagnosis code Z41.1. The diagnosis code Z41.1 should be placed in the first position in item 21 on the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims. A Notice of Exclusion from Medicare Benefits (NEMB) may be used with services excluded from Medicare benefits. 

  6. When the signs or symptoms are present (See L34528 “Coverage Indications, Limitations and/or Medical Necessity”) physicians are encouraged to place the appropriate diagnosis code in the first position with the available symptom diagnosis code in the second position in item 21 of the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims.

  7. Visual Field exams are classified as bilateral procedures where the bilateral adjustment does not apply; the Physician Fee Schedule amount represents payment for both eyes. The procedure should be reported on a single claim line without the 50 or RT/LT modifiers. In the event that the procedure is performed on only one eye per DOS the procedure may be reported with a 52 modifier – (reduced service) and a reduced charge.

  8. Photographs are not separately billable to Medicare.

    The following situation will result in the denial of initially billed Blepharoplasty, Blepharoptosis or Brow Lift services or in some cases as a result of a post payment review.

  9. Physicians’ services submitted without a diagnosis code or not coded to the highest level of accuracy and digit level completeness will be denied as unprocessable.

  10. When blepharoplasty is performed to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure is considered cosmetic and not covered by Medicare. (Use the GY modifier and ICD-10 code Z41.1 for a non-covered denial.)

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(11 Codes)
Group 1 Paragraph

Blepharoplasty of the lower lid (CPT codes 15820, 15821) is generally considered cosmetic and will be denied as non-covered.

Group 1 Codes
Code Description
15820 BLEPHAROPLASTY, LOWER EYELID;
15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD
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)
N/A

CPT/HCPCS Modifiers

Group 1

(5 Codes)
Group 1 Paragraph

The GY modifier must be billed with ICD-10 code Z41.1 for a non-covered denial.

Group 1 Codes
Code Description
50 BILATERAL PROCEDURE: UNLESS OTHERWISE IDENTIFIED IN THE LISTINGS, BILATERAL PROCEDURES THAT ARE PERFORMED AT THE SAME OPERATIVE SESSION SHOULD BE IDENTIFIED BY ADDING THE MODIFIER -50 TO THE APPROPRIATE FIVE DIGIT CODE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09950
52 REDUCED SERVICES: UNDER CERTAIN CIRCUMSTANCES A SERVICE OR PROCEDURE IS PARTIALLY REDUCED OR ELIMINATED AT THE PHYSICIAN'S DISCRETION. UNDER THESE CIRCUMSTANCES THE SERVICE PROVIDED CAN BE IDENTIFIED BY ITS USUAL PROCEDURE NUMBER AND THE ADDITION OF THE MODIFIER -52, SIGNIFYING THAT THE SERVICE IS REDUCED. THIS PROVIDES A MEANS OF REPORTING REDUCED SERVICES WITHOUT DISTURBING THE IDENTIFICATION OF THE BASIC SERVICE. MODIFIER CODE 09952 MAY BE USED AS AN ALTERNATIVE TO MODIFIER -52. NOTE: FOR HOSPITAL OUTPATIENT REPORTING OF A PREVIOUSLY SCHEDULED PROCEDURE/SERVICE THAT IS PARTIALLY REDUCED OR CANCELLED AS A RESULT OF EXTENUATING CIRCUMSTANCES OR THOSE THAT THREATEN THE WELL-BEING OF THE PATIENT PRIOR TO OR AFTER ADMINISTRATION OF ANESTHESIA, SEE MODIFIERS -73 AND -74 (SEE MODIFIERS APPROVED FOR ASC HOSPITAL OUTPATIENT USE).
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
LT LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
RT RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(165 Codes)
Group 1 Paragraph

List the diagnosis code that best describes the patient’s condition. Diagnosis codes must be present on all physician’s service claims and must be coded to the highest level of accuracy and digit level completeness. When the patient requests the claim for cosmetic services be submitted on his/her behalf, the services should be reported with diagnosis code Z41.1 in the first position in item 21 on the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims.

Group 1 Codes
Code Description
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including canthus
C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus
C44.300 Unspecified malignant neoplasm of skin of unspecified part of face
C44.301 Unspecified malignant neoplasm of skin of nose
C44.309 Unspecified malignant neoplasm of skin of other parts of face
C44.311 Basal cell carcinoma of skin of nose
C44.319 Basal cell carcinoma of skin of other parts of face
C44.321 Squamous cell carcinoma of skin of nose
C44.329 Squamous cell carcinoma of skin of other parts of face
C44.391 Other specified malignant neoplasm of skin of nose
C44.399 Other specified malignant neoplasm of skin of other parts of face
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
D03.111 Melanoma in situ of right upper eyelid, including canthus
D03.112 Melanoma in situ of right lower eyelid, including canthus
D03.121 Melanoma in situ of left upper eyelid, including canthus
D03.122 Melanoma in situ of left lower eyelid, including canthus
D04.111 Carcinoma in situ of skin of right upper eyelid, including canthus
D04.112 Carcinoma in situ of skin of right lower eyelid, including canthus
D04.121 Carcinoma in situ of skin of left upper eyelid, including canthus
D04.122 Carcinoma in situ of skin of left lower eyelid, including canthus
D04.39 Carcinoma in situ of skin of other parts of face
D22.111 Melanocytic nevi of right upper eyelid, including canthus
D22.112 Melanocytic nevi of right lower eyelid, including canthus
D22.121 Melanocytic nevi of left upper eyelid, including canthus
D22.122 Melanocytic nevi of left lower eyelid, including canthus
D23.111 Other benign neoplasm of skin of right upper eyelid, including canthus
D23.112 Other benign neoplasm of skin of right lower eyelid, including canthus
D23.121 Other benign neoplasm of skin of left upper eyelid, including canthus
D23.122 Other benign neoplasm of skin of left lower eyelid, including canthus
G24.5 Blepharospasm
H02.001 Unspecified entropion of right upper eyelid
H02.002 Unspecified entropion of right lower eyelid
H02.004 Unspecified entropion of left upper eyelid
H02.005 Unspecified entropion of left lower eyelid
H02.011 Cicatricial entropion of right upper eyelid
H02.012 Cicatricial entropion of right lower eyelid
H02.014 Cicatricial entropion of left upper eyelid
H02.015 Cicatricial entropion of left lower eyelid
H02.021 Mechanical entropion of right upper eyelid
H02.022 Mechanical entropion of right lower eyelid
H02.024 Mechanical entropion of left upper eyelid
H02.025 Mechanical entropion of left lower eyelid
H02.031 Senile entropion of right upper eyelid
H02.032 Senile entropion of right lower eyelid
H02.034 Senile entropion of left upper eyelid
H02.035 Senile entropion of left lower eyelid
H02.041 Spastic entropion of right upper eyelid
H02.042 Spastic entropion of right lower eyelid
H02.044 Spastic entropion of left upper eyelid
H02.045 Spastic entropion of left lower eyelid
H02.051 Trichiasis without entropion right upper eyelid
H02.052 Trichiasis without entropion right lower eyelid
H02.054 Trichiasis without entropion left upper eyelid
H02.055 Trichiasis without entropion left lower eyelid
H02.101 Unspecified ectropion of right upper eyelid
H02.102 Unspecified ectropion of right lower eyelid
H02.104 Unspecified ectropion of left upper eyelid
H02.105 Unspecified ectropion of left lower eyelid
H02.111 Cicatricial ectropion of right upper eyelid
H02.112 Cicatricial ectropion of right lower eyelid
H02.114 Cicatricial ectropion of left upper eyelid
H02.115 Cicatricial ectropion of left lower eyelid
H02.121 Mechanical ectropion of right upper eyelid
H02.122 Mechanical ectropion of right lower eyelid
H02.124 Mechanical ectropion of left upper eyelid
H02.125 Mechanical ectropion of left lower eyelid
H02.131 Senile ectropion of right upper eyelid
H02.132 Senile ectropion of right lower eyelid
H02.134 Senile ectropion of left upper eyelid
H02.135 Senile ectropion of left lower eyelid
H02.141 Spastic ectropion of right upper eyelid
H02.142 Spastic ectropion of right lower eyelid
H02.144 Spastic ectropion of left upper eyelid
H02.145 Spastic ectropion of left lower eyelid
H02.151 Paralytic ectropion of right upper eyelid
H02.152 Paralytic ectropion of right lower eyelid
H02.154 Paralytic ectropion of left upper eyelid
H02.155 Paralytic ectropion of left lower eyelid
H02.201 Unspecified lagophthalmos right upper eyelid
H02.202 Unspecified lagophthalmos right lower eyelid
H02.204 Unspecified lagophthalmos left upper eyelid
H02.205 Unspecified lagophthalmos left lower eyelid
H02.20A Unspecified lagophthalmos right eye, upper and lower eyelids
H02.20B Unspecified lagophthalmos left eye, upper and lower eyelids
H02.20C Unspecified lagophthalmos, bilateral, upper and lower eyelids
H02.211 Cicatricial lagophthalmos right upper eyelid
H02.212 Cicatricial lagophthalmos right lower eyelid
H02.214 Cicatricial lagophthalmos left upper eyelid
H02.215 Cicatricial lagophthalmos left lower eyelid
H02.21A Cicatricial lagophthalmos right eye, upper and lower eyelids
H02.21B Cicatricial lagophthalmos left eye, upper and lower eyelids
H02.21C Cicatricial lagophthalmos, bilateral, upper and lower eyelids
H02.221 Mechanical lagophthalmos right upper eyelid
H02.222 Mechanical lagophthalmos right lower eyelid
H02.224 Mechanical lagophthalmos left upper eyelid
H02.225 Mechanical lagophthalmos left lower eyelid
H02.22A Mechanical lagophthalmos right eye, upper and lower eyelids
H02.22B Mechanical lagophthalmos left eye, upper and lower eyelids
H02.22C Mechanical lagophthalmos, bilateral, upper and lower eyelids
H02.231 Paralytic lagophthalmos right upper eyelid
H02.232 Paralytic lagophthalmos right lower eyelid
H02.234 Paralytic lagophthalmos left upper eyelid
H02.235 Paralytic lagophthalmos left lower eyelid
H02.23A Paralytic lagophthalmos right eye, upper and lower eyelids
H02.23B Paralytic lagophthalmos left eye, upper and lower eyelids
H02.23C Paralytic lagophthalmos, bilateral, upper and lower eyelids
H02.31 Blepharochalasis right upper eyelid
H02.32 Blepharochalasis right lower eyelid
H02.34 Blepharochalasis left upper eyelid
H02.35 Blepharochalasis left lower eyelid
H02.411 Mechanical ptosis of right eyelid
H02.412 Mechanical ptosis of left eyelid
H02.413 Mechanical ptosis of bilateral eyelids
H02.421 Myogenic ptosis of right eyelid
H02.422 Myogenic ptosis of left eyelid
H02.423 Myogenic ptosis of bilateral eyelids
H02.431 Paralytic ptosis of right eyelid
H02.432 Paralytic ptosis of left eyelid
H02.433 Paralytic ptosis of bilateral eyelids
H02.521 Blepharophimosis right upper eyelid
H02.522 Blepharophimosis right lower eyelid
H02.524 Blepharophimosis left upper eyelid
H02.525 Blepharophimosis left lower eyelid
H02.531 Eyelid retraction right upper eyelid
H02.532 Eyelid retraction right lower eyelid
H02.534 Eyelid retraction left upper eyelid
H02.535 Eyelid retraction left lower eyelid
H02.831 Dermatochalasis of right upper eyelid
H02.832 Dermatochalasis of right lower eyelid
H02.834 Dermatochalasis of left upper eyelid
H02.835 Dermatochalasis of left lower eyelid
H57.811 Brow ptosis, right
H57.812 Brow ptosis, left
H57.813 Brow ptosis, bilateral
H57.8A1 Foreign body sensation, right eye
H57.8A2 Foreign body sensation, left eye
H57.8A3 Foreign body sensation, bilateral eyes
Q10.0 Congenital ptosis
Q10.1 Congenital ectropion
Q10.2 Congenital entropion
Q10.3 Other congenital malformations of eyelid
Q11.1 Other anophthalmos
Q15.9 Congenital malformation of eye, unspecified
Q18.8 Other specified congenital malformations of face and neck
Z44.21 Encounter for fitting and adjustment of artificial right eye
Z44.22 Encounter for fitting and adjustment of artificial left eye

Group 2

(47 Codes)
Group 2 Paragraph

For Codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequel may be used.

Group 2 Codes
Code Description
S00.10XA Contusion of unspecified eyelid and periocular area, initial encounter
S00.11XA Contusion of right eyelid and periocular area, initial encounter
S00.12XA Contusion of left eyelid and periocular area, initial encounter
S01.101A Unspecified open wound of right eyelid and periocular area, initial encounter
S01.102A Unspecified open wound of left eyelid and periocular area, initial encounter
S01.111A Laceration without foreign body of right eyelid and periocular area, initial encounter
S01.112A Laceration without foreign body of left eyelid and periocular area, initial encounter
S01.119A Laceration without foreign body of unspecified eyelid and periocular area, initial encounter
S01.121A Laceration with foreign body of right eyelid and periocular area, initial encounter
S01.122A Laceration with foreign body of left eyelid and periocular area, initial encounter
S01.129A Laceration with foreign body of unspecified eyelid and periocular area, initial encounter
S01.131A Puncture wound without foreign body of right eyelid and periocular area, initial encounter
S01.132A Puncture wound without foreign body of left eyelid and periocular area, initial encounter
S01.139A Puncture wound without foreign body of unspecified eyelid and periocular area, initial encounter
S01.141A Puncture wound with foreign body of right eyelid and periocular area, initial encounter
S01.142A Puncture wound with foreign body of left eyelid and periocular area, initial encounter
S01.149A Puncture wound with foreign body of unspecified eyelid and periocular area, initial encounter
S01.151A Open bite of right eyelid and periocular area, initial encounter
S01.152A Open bite of left eyelid and periocular area, initial encounter
S01.159A Open bite of unspecified eyelid and periocular area, initial encounter
S05.20XA Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, initial encounter
S05.21XA Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial encounter
S05.22XA Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, initial encounter
S09.92XA Unspecified injury of nose, initial encounter
S09.93XA Unspecified injury of face, initial encounter
S16.8XXA Other specified injury of muscle, fascia and tendon at neck level, initial encounter
S16.9XXA Unspecified injury of muscle, fascia and tendon at neck level, initial encounter
S19.80XA Other specified injuries of unspecified part of neck, initial encounter
S19.81XA Other specified injuries of larynx, initial encounter
S19.82XA Other specified injuries of cervical trachea, initial encounter
S19.83XA Other specified injuries of vocal cord, initial encounter
S19.84XA Other specified injuries of thyroid gland, initial encounter
S19.85XA Other specified injuries of pharynx and cervical esophagus, initial encounter
S19.89XA Other specified injuries of other specified part of neck, initial encounter
S19.9XXA Unspecified injury of neck, initial encounter
T26.00XA Burn of unspecified eyelid and periocular area, initial encounter
T26.01XA Burn of right eyelid and periocular area, initial encounter
T26.02XA Burn of left eyelid and periocular area, initial encounter
T26.20XA Burn with resulting rupture and destruction of unspecified eyeball, initial encounter
T26.21XA Burn with resulting rupture and destruction of right eyeball, initial encounter
T26.22XA Burn with resulting rupture and destruction of left eyeball, initial encounter
T26.40XA Burn of unspecified eye and adnexa, part unspecified, initial encounter
T26.41XA Burn of right eye and adnexa, part unspecified, initial encounter
T26.42XA Burn of left eye and adnexa, part unspecified, initial encounter
T26.50XA Corrosion of unspecified eyelid and periocular area, initial encounter
T26.51XA Corrosion of right eyelid and periocular area, initial encounter
T26.52XA Corrosion of left eyelid and periocular area, initial encounter
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
12/28/2023 R5

12/28/2023: Under CPT/HCPCS Codes Group 1 Codes: Revised description for CPT code 67901. Biannual review completed 11/20/2023 with no change in coverage.

10/01/2023 R4

Posted 09/28/2023: Under ICD-10 Codes that Support Medical Necessity Group 1 Codes added H57.8A1, H57.8A2, and H57.8A3 due to the 2024 Annual ICD-10-CM update.

04/28/2022 R3

Posted 04/28/2022 Review completed 04/04/2022.

04/30/2020 R2

04/30/2020 Review completed 3/24/2020. Relocated coding guidance from the Documentation Requirements section of LCD L34528 Blepharoplasty, Blepharoptosis and Brow Lift to #2 in the Article Text section of this document. Removed redundant language from same section. Relocated references to the Social Security Act and CR 10236 from the Article Text section to the CMS National Coverage section. Removed specific Bill Type and Revenue codes. Typographical errors corrected. Reformatted numbers and tables.

08/29/2019 R1

10/31/2019 Added ICD-10 codes unintentionally omitted from Table 1 of the article when the codes were migrated from the LCD: H02.005, H02.011, H02.012, H02.014, H02.015, H02.021, H02.022, H02.024, H02.025, H02.031, H02.032, H02.034, H02.035, H02.041, H02.042, H02.044, H02.045, H02.051, H02.052, H02.054, H02.055, H02.101, H02.102, H02.104, H02.105, H02.111, H02.112, H02.114, H02.115, H02.121, H02.122, H02.124, H02.125, H02.131, H02.132, H02.134, H02.135, H02.141, H02.142, H02.144, H02.145, H02.151, H02.152, H02.154, H02.155, H02.201, H02.202, H02.204. Corrected minor typo. Added codes to Modifier section.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Keywords

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