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ptosis correction with levator muscle advancement

Melissa Posted Mon 24th of October, 2016 09:14:54 AM
should this be two separate cpt codes, I was coding 67904, but I am unsure based on physicians wording: A 15-blade was used to create a skin incision; Westcott scissors were used to resect and remove excessive and redundant upper eyelid tissue. Bipolar cautery was used to confirm complete hemostasis; OR lights were turned on and eyelid height and contour examined, the patient continued to have persistent ptosis due to levator problems; a separate and distinct operation was therefore indicated. New incision made through the septum, the postseptal fat was elevated off the levator muscle complex. the levator was attenuated and appeared to be detached; a fresh surgical incision was made at the edge of the levator aponeurisis which was advanced and imbricated with 6-0 mersilene suture. eyelid height and contour examined, bipolar cautery was used to obtain hemostasis.
SuperCoder Answered Tue 25th of October, 2016 01:21:34 AM

The intent of the procedure was to correct Ptosis. Provider tried to correct it by removing excessive and redundant upper eyelid tissue in the first attempt but could not correct the Ptosis. Provider then used the seperate approach to correct Ptosis by levator advancement. Since the intent of the procedure was to correct Ptosis, provider would be paid for the services of Ptosis correction only. The most appropriate code in this case would be CPT code 67904.

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