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LCD Reference Article Billing and Coding Article

Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow

A57025

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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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General Information

Source Article ID
N/A
Article ID
A57025
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
06/25/2023
Revision Ending Date
N/A
Retirement Date
N/A

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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

Internet-Only Manuals (IOMs):

  • CMS IOM Publication, 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)

National Correct Coding Initiative (NCCI):

  • Medicare NCCI Policy Manual,
    • Chapter 8, Section D. Ophthalmology

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34028 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Effective October 1, 2017, The Center for Medicare & Medicaid Services (CMS) revised policy may allow payment to be made for a medically necessary upper eyelid blepharoptosis when performed with (noncovered) cosmetic blepharoplasty on the same eye during the same visit.

For correct coding guidelines and specific applicable code combinations prior to billing Medicare, refer to the Medicare NCCI Policy Manual, Chapter 8, Section D. Ophthalmology.

Correct coding dictates that removal of malignant and benign lesions requires a different set of codes than the codes listed in this article.

  • Removal of malignant lesions should be reported with CPT codes 11640-11646.
  • Removal of benign lesions should be reported with CPT codes 11440-11446, 67840 or 67850.
  • Mohs surgery should be reported with CPT codes 17311-17315.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The submitted medical record must include results of pertinent diagnostic tests and operative reports as appropriate, documentation to support the medical necessity of blepharoptosis repair, brow ptosis repair, and blepharoplasty procedures:
    • Clinical notes, supporting a decrease in visual field (peripheral vision and/or upper field vision) demonstrating a 12 to 15 degree superior loss or 24% to 30% superior visual field impairment, near or far visual impairment, or difficulty reading.
    • Patient complaints and physical findings, for example:
      • Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.
      • Chronic eyelid dermatitis due to redundant eyelid skin.
      • Lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing.
      • Entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation.
      • Difficulty wearing prosthesis.
    • Margin reflex distance (MRD1) of 2 mm or less.
    • A palpebral fissure height on down-gaze of 1 mm or less, (measured with the patient fixating on an object in down–gaze with the ipsilateral brow relaxed and the contralateral lid elevated).
    • The presence of Hering’s Law meeting one of the above criteria in bullets 3 or 4. Hering’s Law of equal innervation to both upper eyelids may be considered in the documentation to perform bilateral ptosis repair in which the position of one upper eyelid has marginal criteria and the other eyelid had good supportive documentation for ptosis surgery.
    • Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment.
  5. Preoperative photographs in the form of prints or slides are required to be submitted with the medical record to support medical necessity of blepharoptosis repair, brow ptosis repair and blepharoplasty procedures if the record is not sufficient to determine medical necessity. If photographs are requested to support the documentation, photograph guidelines that support medical necessity include:
    • The photographs must be frontal view, 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 pseudo-lid margin.
    • For CPT codes 15820-15823 or 67901-67908: If redundant skin coexists with true lid ptosis, additional photos taken with the upper lid skin retracted to show the actual position of the true lid margin are supportive of medical necessity.
    • Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.
    • Separate from the photographs, documentation in the medical record of the indicated distance thresholds (e.g., 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that overhangs the eyelid margin [pseudoptosis]) is helpful to demonstrate medical necessity.

NOTE: If both a blepharoplasty and a blepharoptosis repair are planned, both must be individually documented. The medical necessity criteria for each procedure must be met and the additional required testing criteria demonstrate visual impairment that cannot be addressed by one procedure alone. This may require two sets of photographs showing the effect of drooping of redundant skin (drooping of brows and its correction by taping), and the actual presence of blepharoptosis with drooping of the upper eyelid.

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(25 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.


The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906 and 67908.

 Group 1 Codes
Code Description
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
H02.831 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
Q10.0 Congenital ptosis

Group 2

(84 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923 and 67924.

 Group 2 Codes
Code Description
G51.0 Bell's palsy
H01.011 Ulcerative blepharitis right upper eyelid
H01.012 Ulcerative blepharitis right lower eyelid
H01.014 Ulcerative blepharitis left upper eyelid
H01.015 Ulcerative blepharitis left lower eyelid
H01.01A Ulcerative blepharitis right eye, upper and lower eyelids
H01.01B Ulcerative blepharitis left eye, upper and lower eyelids
H01.021 Squamous blepharitis right upper eyelid
H01.022 Squamous blepharitis right lower eyelid
H01.024 Squamous blepharitis left upper eyelid
H01.025 Squamous blepharitis left lower eyelid
H01.02A Squamous blepharitis right eye, upper and lower eyelids
H01.02B Squamous blepharitis left eye, upper and lower eyelids
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
H02.111 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
H02.211 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
H02.531 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
H04.521 Eversion of right lacrimal punctum
H04.522 Eversion of left lacrimal punctum
H04.523 Eversion of bilateral lacrimal punctum
Q10.1 Congenital ectropion
Q10.2 Congenital entropion
Q10.3 Other congenital malformations of eyelid
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

 Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

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 Group 1 Codes

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Additional ICD-10 Information

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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.

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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.

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Other Coding Information

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Group 1 Paragraph

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 Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
06/25/2023 R4

Article revised and published on 05/11/2023 effective for dates of service on and after 06/25/2023 as a non-discretionary update to correct coding guidance and ICD-10-CM codes that were not in alignment with the LCD indications. Therefore, the following changes have been made in order to provide correct coding guidance and to ensure consistency with the LCD.

The ‘Coding Guidance’ section has been revised to indicate correct coding dictates that removal of malignant lesions should be reported with CPT codes 11640-11646, benign lesions should be reported with CPT codes 11440-11446, 67840 or 67850 and Mohs surgery should be reported with CPT codes 17311-17315.

Consistent with the LCD, the following CPT code has been added to the CPT/HCPCS Code Group 2 Codes and the ICD-10-CM Codes that Support Medical Necessity Group 2 Codes: 67912.

The following ICD-10-CM codes have been moved from Group 2 ICD-10-CM Codes to Group 1 ICD-10-CM Codes: H02.521, H02.522, H02.524, H02.525.

The CPT codes in Group 2 describe revision and repair of eyelid defects (ectropion and entropion). Therefore, the following ICD-10-CM codes have appropriately been removed from Group 1 ICD-10-CM Codes: H02.012, H02.015, H02.022, H02.025, H02.032, H02.035, H02.042, H02.045, H02.112, H02.115, H02.122, H02.125, H02.132, H02.135, H02.142, H02.145, H02.152, H02.155.

The following ICD-10-CM codes, located in the Group 1 ICD-10-CM Codes, have been deleted from the article: H02.401, H02.402, H02.403 as these are unspecified codes and providers should report more specific codes for mechanical, myogenic or paralytic ptosis.

The following ICD-10-CM codes, located in the Group 2 ICD-10-CM Codes, have been deleted from the article as malignant and benign lesions should be reported with a different set of codes: C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, ,D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D22.111, D22.112, D22.121, D22.122, D23.111, D23.112, D23.121, D23.122.

The following ICD-10-CM codes, located in the Group 2 ICD-10-CM Codes were deleted from the article as these codes do not apply to eyelid surgeries: C44.301, C44.309, C44.311, C44.319, C44.321, C44.329, C44.391, C44.399, C47.0, C49.0, D22.39, D23.39.

The following ICD-10-CM code, located in the Group 2 ICD-10-CM Codes has been deleted from the article: G51.2 as Melkersson-Rosenthal syndrome does not appear to cause symptoms that would require the type of eye surgery addressed by the LCD.

The following unspecified ICD-10-CM codes, located in the Group 2 ICD-10-CM Codes, were deleted from the article as more specific codes should be reported for ulcerative or squamous blepharitis: H01.001, H01.002, H01.004, H01.005.

The following unspecified ICD-10-CM codes, located in the Group 2 ICD-10-CM Codes, were deleted from the article as more specific codes should be reported for cicatricial, mechanical, senile, or spastic ectropion: H02.001, H02.002, H02.004, H02.005, H02.101, H02.102, H02.104, H02.105.

The following unspecified ICD-10-CM codes, located in the Group 2 ICD-10-CM Codes, were deleted from the article as more specific codes should be reported for cicatricial, mechanical, or paralytic lagophthalmos: H02.201, H02.202, H02.204, H02.205.

The following ICD-10-CM codes were deleted from the Group 2 ICD-10-CM Codes as they are appropriately placed in the Group 1 ICD-10-CM Codes: H02.411, H02.412, H02.413, H02.421, H02.422, H02.423, H02.431, H02.432, H02.433, Q10.0.

The following ICD-10-CM code, located in the Group 2 ICD-10-CM Codes was deleted from the article: Q11.1 as this code refers to congenital absence of the eye and can be agenesis or aplasia which would not require the type of eye surgeries addressed by the LCD.

The following ICD-10-CM codes have been added to the Group 2 ICD-10-CM Codes: H01.011, H01.012, H01.014, H01.015, H01.01A, H01.01B, H01.021, H01.022, H01.024, H01.025, H01.02A, H01.2B.

Documentation requirements for bullets #4 and #5 have been revised to add clarification. Additionally, two additional patient complaints and physical findings have been added to documentation requirement bullet #4 and visual field testing has been added to the list of notes required.
10/28/2021 R3

Article revised and published on 10/28/2021 effective for dates of service on and after 03/21/2021. Current Procedural Terminology (CPT) code 67961 has been removed from the article. CPT codes 67914, 67915, 67916, 67917, 67921, 67922, 67923 and 67924 have been removed from the Group 1 CPT codes and placed in a newly created Group 2. CPT Codes 67909 and 67911 have been added to Group 2 CPT codes and to the new ICD-10-CM Group 2 Paragraph. ICD-10-CM codes H02.401, H02.402 and H02.403 were added to the Group 1 ICD-10-CM codes that support medical necessity. A new ICD-10-CM Group 2 codes that support medical necessity was created to support the new CPT Group 2 codes.
05/27/2021 R2

Article revised and published on 05/27/2021 to revise bullet point #5 in the ‘Documentation Requirements’ section for clarification purposes in response to questions from prior auth. Minor formatting changes were made in the coding section.
03/21/2021 R1

This revised Billing and Coding Article published 02/04/2021 will become effective 03/21/2021. The proposed LCD and related Billing and Coding Article will provide limited coverage for upper and lower blepharoplasty as well as repair of brow ptosis when performed for functional indications.

2020PITLAB019
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