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Question: A patient presented to their ophthalmologist with severe discomfort and dryness in their left eye. The ophthalmologist examined and diagnosed the patient with upper eyelid retraction. The provider recommended surgical correction to treat the condition.

Two weeks later, the patient returned to the clinic for the surgery. The operative note states, 鈥淎 horizontal incision was made in the upper eyelid crease. Dissection was carried out to the levator aponeurosis. The levator was recessed and reattached at a lower point to correct the lid retraction. The incision was then closed with absorbable sutures.鈥�

What procedure codes do I need to assign for the surgery?

Wyoming Subscriber

Answer: You鈥檒l assign 67911 (Correction of lid retraction) to report the surgical procedure.

An eyelid retraction occurs when the eyelid pulls back from the eye, which can cause pain and possible vision problems. Ophthalmologists can recommend surgery to correct the issue when conservative treatments are unsuccessful.

Additionally, you鈥檒l assign H02.534 (Eyelid retraction left upper eyelid) to report the left upper eyelid retraction diagnosis. This diagnosis shows the medical necessity for the procedure, but the medical documentation should also specify the previous treatment attempts that were unsuccessful.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC