Case Studies—Eye and Ocular Adnexa Operative and Emergency Department Report - Operative Report

1. Refer to the key operative term in the Alphabetic Index and note the code range. What documentation is needed from the record to correctly assign a CPT code(s)?

2. Time to Code:

1. Determine whether the procedure was performed on the upper or lower eyelids (unilateral or bilateral). Next, note that the diagnostic information contributes to the coding in this case (excessive skin weighting down lid).

The blepharoplasty codes appear in the Integumentary System section. More extensive eyelid repair codes appear in the Eye and Ocular Adnexa section (e.g., 67901).

2. Index:
Blepharoplasty
Code(s):
15823-50 Blepharoplasty; upper eyelid; with excessive skin weighting down lid