Every procedural code tells a different story. So, how does CPT code 67904 differ from other eyelid procedures? Approximately 8% of the U.S. population, nearly 20 million Americans, experience visual impairments, ranging from poor vision to blindness. These impairments stem from various causes, including cataracts and macular degeneration.
But did you know that ptosis can also obstruct the visual field? Thankfully, there is a surgical solution for this condition. As an ophthalmologist, you may even be performing this procedure regularly. But how often do you face claim denials for this ptosis repair surgery due to a simple coding mistake?
Let us walk you through the specifics of CPT code 67904 so you can accurately document and bill for this procedure!
CPT Code 67904 – Description
CPT code 67904 describes an eyelid procedure, specifically blepharoptosis repair surgery. In simple terms, it refers to a surgical procedure in which healthcare providers, usually oculoplastic surgeons, correct a drooping eyelid to either:
- Remove obstruction from the patient’s visual field
- Improve cosmetic appearance
But how does a surgeon do that? He uses an external approach to tighten the levator muscle, which controls eyelid movement. This method is ideal for people with loose or severely wrinkled eyelids.
During this procedure, the provider incises the upper eyelid skin to locate the levator muscle. He then uses stitches to attach it to the tarsus (connective eyelid tissue), effectively raising the eyelid.
In short, CPT code 67904 covers a levator advancement or resection surgery via an external approach.
Scenarios Where CPT Code 67904 is Applicable
Here are some applicable scenarios of CPT code 67904:
Ptosis Due to Myasthenia Gravis (MG)
Myasthenia gravis (MG), an autoimmune disease affecting both women and men, can cause ptosis. Let’s consider this scenario:
Suppose a 35-year-old woman with MG experiences vision obstruction due to unilateral ptosis. Her left eyelid droops 2 mm below the upper edge of the iris, making it difficult for her to perform daily tasks.
Tired of this problem, she visits her nearest ophthalmology clinic. After a thorough examination, the doctor performs a ptosis repair surgery to tighten her levator muscle via an external approach. He then bills for this procedure using CPT code 67904. Since he operated on her left eyelid, the provider used the modifier LT with this code.
Congenital Ptosis Repair
Let’s consider a case of congenital ptosis! Assume a 3-year-old toddler with unilateral congenital ptosis is eventually brought to an outpatient clinic by his parents. The primary reason? The drooping increased with time and started obstructing his vision.
The doctor evaluates the child and notices that his glasses are no longer effective. To prevent the risk of astigmatism, he performs ptosis repair surgery on the child’s right eyelid via an external approach.
The billing team then files a claim for this procedure using CPT code 67904. They also use modifier RT with this code to indicate the location of the procedure.
Bilateral Ptosis Repair after a Stroke
Suppose a 65-year-old man develops bilateral ptosis following a stroke. His drooping eyelids significantly reduce his field of vision, prompting him to seek medical attention.
He visits an outpatient clinic where the ophthalmologist reviews his medical records and determines that the levator muscle weakness is due to stroke-related nerve damage. After several assessments, the surgeon decides to correct the damage surgically.
During the procedure, he incises both upper eyelids and tightens the levator muscles to restore eyelid function. Since this is a bilateral procedure, the billing team applies modifier 50 to CPT code 67904.
Applicable Modifiers for CPT Code 67904
Here are a few modifiers you can apply to CPT code 67904, depending on the situation:
Modifier LT
Laterality modifiers can help insurance companies identify which eyelid you performed the surgery on. Use modifier LT with CPT code 67904 if you performed ptosis repair on the patient’s left eye.
Modifier RT
Append modifier RT to 67904 if you performed ptosis repair on the right eyelid.
Modifier 50
For bilateral ptosis repair, apply modifier 50 to CPT code 67904 to indicate the procedure was performed on both eyes during the same surgical session.
Modifier 59
Report CPT code 67904 with modifier 59 when ptosis repair surgery is unrelated to other procedures you performed on the same day and on the same patient. However, use this modifier only when there are no other alternatives to describe why the procedure is distinct.
Modifier GA
If the procedure is cosmetic, Medicare will likely deny the claim. In this case, append modifier GA to 67904 to indicate that an Advance Beneficiary Notice (ABN) of non-coverage is on file.
CPT Code 67904 – Billing & Reimbursement Guidelines
Compliance is everything for proper reimbursements. Hence, if you want to avoid claim denial for CPT code 67904, follow these billing and reimbursement guidelines:
Confirm Medical Necessity before Billing
As mentioned before, blepharoptosis repair surgery is performed for either functional or cosmetic purposes. Remember, most insurance companies, including Medicare, only cover ptosis repair if medically necessary.
Therefore, verify that the procedure is not cosmetic and is essential for functional reasons, such as removing visual obstruction, before filing any claim.
Apply Appropriate Modifiers
Modifiers, especially laterality modifiers, are essential to specify which eyelid was treated. Therefore, assign the correct codes, such as RT, LT, or 50, when filing a claim for eyelid repair surgery. Use the modifier GA or GY if you performed the procedure to improve appearance.
Justify the Procedure with Proper Documentation
You must justify the medical necessity of CPT code 67904 with proper documentation. Therefore, include the following details in the patient’s medical record:
- Preoperative assessments and their results
- Relevant medical history (e.g., patient complaints, symptoms)
- The correct ICD-10 code (e.g., H02.40 for unspecified ptosis, Q10.0 for congenital ptosis, H02.43 for paralytic ptosis)
- Operative report specifying the external approach for levator muscle tightening
Follow Payer-Specific Billing Rules
Each payer has different rules and billing requirements for various procedures. Therefore, check their guidelines to ensure compliance. For example, if you are filing Medicare claims, review their coverage criteria, NCCI, and OPPS requirements. If you expect Medicare to deny the procedure, issue an ABN and use an appropriate modifier (GA or GY).
Conclusion
To summarize, CPT code 67904 covers eyelid defect repair surgery, specifically an external levator advancement or resection procedure. Healthcare providers use this code every day, but only a few fully understand its true implications.
You can use CPT code 67904 to report ptosis repair for both functional and cosmetic reasons. However, insurance companies, including Medicare, cover only medically necessary procedures. We have covered this code comprehensively in our blog to help you use it confidently. But if you need professional coding expertise, you can always opt for our ophthalmology billing services.
