Abstract from Documentation: Refer to Repair, Eyelid in the Alphabetic Index. What code range is applicable?

Preoperative Diagnosis: Left upper lid laceration

Postoperative Diagnosis: Left upper lid laceration

Procedure: Left upper lid laceration repair with exam under anesthesia

Anesthesia: General

Complications: There were no complications.

Indications: This 4-year-old child suffered a dog bite to his left upper lid and was unable to be repaired successfully in the emergency room. After obtaining informed consent, he was taken to the operating room.

Description of the Procedure: The patient was prepped and draped in the usual sterile fashion. The wound margins were reapproximated using 6-0 absorbable suture and 2 lid margin sutures were placed using 6-0 silk. The injury was limited to the epidermis and part of the dermis. There was no structural damage to the blood vessels or deeper tissue layers. The lid was noted to be in good position, and then all skin lacerations were closed using a combination of 6-0 running and 6-0 interrupted nylon.

The patient then had his eye dilated, and exam under anesthesia was carried out using an indirect ophthalmoscope. There was no evidence of trauma to the globe or the posterior pole.

The patient was taken to the recovery room in good condition and will be sent home today to follow up in my office.

Wound, Suture (67930–67935) The code selection is determined by extent of the wound repair; was it partial thickness or full thickness? Since the suturing was limited to the epidermis and part of the dermis, it is a partial thickness wound repair.


CPT Code Assignment:

67930-E1 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness
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