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Outpatient Facility Coding Alert

Reader Question:

Look for Evidence of Surgical Approach Changes

Question: Our ophthalmologist performed a blepharoptosis repair using the frontalis muscle technique. He started with the external approach, but his visualization was limited using that approach, so he then changed his technique and used an internal approach instead. We reported both 67903 and 67904 and appended modifier 59 to 67904, but the insurer denied the charge for 67904. According to the CCI edits, we should be able to collect for 67904 if we append modifier 59. Should we appeal? Subscriber

Answer: No, you should not appeal. Typically, you would only report 67903 (Repair of blepharoptosis; [tarso] levator resection or advancement, internal approach) and 67904 (…external approach) together in cases when the surgeon addresses both eyes, using an internal approach on one and an external approach on the other. In these cases, you would likely use the eye modifiers (such as E1, Upper left eyelid, and E4, Lower right eyelid) to show the insurer that you addressed different eyes.

When you change from one approach to another, you’ll just report the code for the final procedure that the surgeon completes rather than the attempted approach and the final one. Therefore, in this situation, you would report 67903 only.

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