H02.23A — Paralytic lagophthalmos right eye, upper and lower eyelids
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Billing and coding guidance in this policy complements and references Local Coverage Determination L34425; claims should be supported per the documentation requirements specified in LCD L34425.
- List the appropriate CPT code for the procedure and include any applicable modifiers; adhere to Medicare global surgery and CCI (correct coding initiative) rules for eyelid surgeries.
- Submit physicians' services and diagnostic tests with a diagnosis code that supports medical necessity and code to the greatest level of specificity (full digit completeness).
- Use the diagnosis code based on diagnostic test results as the primary diagnosis; if test results are normal or inconclusive, use the diagnosis code for the sign or symptom that prompted the test as the primary diagnosis.
Key Coverage Criteria
- No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
- Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
- 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.
20 Active Policies
L34528 — Blepharoplasty, Blepharoptosis and Brow Lift
J05
A56908 — Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift
J05
A57025 — Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J09
L34028 — Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J09
Related Codes
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