Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow

Coverage is limited to medically necessary blepharoptosis, brow ptosis, and blepharoplasty procedures that produce documented functional impairment (e.g., superior visual field loss of 12–15 degrees or 24%–30% impairment, MRD1 ≤2 mm, or palpebral fissure ≤1 mm on down-gaze) or other specified pathology (ectropion, entropion, chronic dermatitis, prosthesis intolerance). Detailed, legible documentation including diagnostic test results, MRD and fissure measurements, and frontal (and when required, retracted or oblique) preoperative photographs must be maintained; coding for lesion removal and Mohs surgery must be reported with the specified CPT codes. Cosmetic procedures alone are noncovered, but a medically necessary ptosis repair may be payable when performed on the same eye and same visit as a noncovered cosmetic blepharoplasty if all medical necessity criteria are met.

"Blepharoptosis repair is covered when visual field testing demonstrates a superior visual field loss of 12–15 degrees or a superior visual field impairment of 24%–30%."