Bilateral Upper Lid Blepharoplasty
Medical Specialty: Ophthalmology
Description:
Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.
(Medical Transcription Sample Report
PREOPERATIVE DIAGNOSIS:
Bilateral upper eyelid dermatochalasis.
POSTOPERATIVE DIAGNOSIS:
Same.
PROCEDURE:
Bilateral upper lid blepharoplasty (CPT 15822).
ANESTHESIA:
Lidocaine with 1:100,000 epinephrine.
DESCRIPTION OF PROCEDURE:
This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The procedure, alternatives, risks, and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested that this corrective repair be undertaken, and a consent was signed. The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started, and sedation anesthesia was administered IV after preoperative p.o. sedation. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. The excess and redundant skin of the upper lids, producing redundancy and impairment of lateral vision, was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.
The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction. The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.
The face was prepped and draped in the usual sterile manner.
After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and the herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised, and the stalk was meticulously cauterized with the bipolar cautery unit. A similar procedure was performed, exposing the herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.
At the end of the operation, the patient’s vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.
The procedures were completed without complication and were tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications were prescribed, and post-op instructions were given to the responsible party.
The patient was released to return home in satisfactory condition.
SCENARIO OVERVIEW (Coding Context)
- Patient: 65-year-old female
- Specialty: Ophthalmology
- Condition: Bilateral upper eyelid dermatochalasis causing visual impairment
- Procedure: Bilateral upper lid blepharoplasty
- Anesthesia: Local anesthesia with epinephrine (with IV sedation)
- Laterality: Bilateral
- Purpose: Functional (visual field impairment), not cosmetic
ICD-10-CM DIAGNOSIS CODES
H02.831 – Dermatochalasis of right upper eyelid
H02.834 – Dermatochalasis of left upper eyelid
Rationale:
- The preoperative and postoperative diagnoses document bilateral upper eyelid dermatochalasis
- ICD-10-CM requires separate laterality-specific codes for each eyelid
- Documentation supports functional impairment (“impairment of lateral vision”), which is critical for medical necessity
CPT PROCEDURE CODE
15822 – Blepharoplasty, upper eyelid
Rationale:
- The procedure performed was upper eyelid blepharoplasty
- Excess skin was excised with the removal of redundant skin, orbicularis muscle, and herniated orbital fat
- Code 15822 describes upper eyelid blepharoplasty
- CPT 15822 is inherently bilateral when documented as such
- Do NOT append modifier -50
- Do NOT bill units = 2
ANESTHESIA CODING (FOR FACILITY / ANESTHESIA PROVIDER ONLY)
- Local anesthesia and IV sedation are included in the surgical package
- No separate anesthesia CPT is reported by the surgeon
- Anesthesia coding would be handled separately by anesthesia services, if applicable
CODES NOT REPORTED (WITH RATIONALE)
- 15820 (Lower eyelid blepharoplasty)
Not performed; procedure involved upper lids only
- Cosmetic diagnosis codes (e.g., Z41.1)
Not appropriate due to documented visual impairment
- Modifier -50 (Bilateral procedure)
Not appended because 15822 is a bilateral code by definition
- Separate fat excision or muscle excision codes
These are bundled into blepharoplasty
FINAL CODING SUMMARY
| Type | Code | Description |
| ICD-10-CM | H02.831 | Dermatochalasis of right upper eyelid |
| ICD-10-CM | H02.834 | Dermatochalasis of left upper eyelid |
| CPT | 15822 | Upper eyelid blepharoplasty (bilateral) |
KEY CODING PRINCIPLES HIGHLIGHTED
- Laterality matters for ICD-10-CM, not for CPT in this case
- Functional blepharoplasty requires documentation of visual field impairment
- Upper eyelid blepharoplasty includes:
- Skin excision
- Muscle excision
- Fat removal
- CPT 15822 is billed once, even when performed bilaterally