H01.011 — Ulcerative blepharitis right upper eyelid
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- If photographs are requested to support documentation, they must be submitted as prints or slides with the medical record.
- Documentation should include measured distance thresholds (for example MRD1 and palpebral fissure measurements) to demonstrate medical necessity.
- Medical records must be maintained, legible, include patient identifiers and dates of service, and contain the legible signature of the responsible practitioner.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Medically necessary upper eyelid blepharoptosis repair may be paid when performed concurrently with cosmetic blepharoplasty on the same eye during the same visit if medical necessity is documented.
- Visual field impairment demonstrated by testing or clinical notes showing a 12–15 degree superior visual field loss or a 24%–30% superior visual field impairment constitutes medical necessity for blepharoptosis repair.
- Near or distance visual impairment or documented difficulty reading attributable to upper eyelid drooping supports medical necessity for surgery.
- Patient complaints or physical findings of interference with vision or visual field (for example difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue) support medical necessity.
- Chronic eyelid dermatitis caused by redundant eyelid skin is an indication for blepharoplasty.
- Lower eyelid ectropion causing eye irritation, inflammation, or excessive tearing is an indication for surgical repair.
9 Active Policies
L34028 — Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J09
A57637 — Billing and Coding: Visual Field Examination
J09
A57025 — Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J09
L33766 — Visual Field Examination
J09
Related Codes
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