2025 CPT code 67909
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Revision of previous eyelid surgery to correct drooping eyelid (blepharoptosis).
Modifiers E1-E4 (to specify the affected eyelid) are informational and may be required by some payers. Modifiers 50 (bilateral procedure), 51 (multiple procedures), and 22 (increased procedural services) may also apply under specific circumstances.
Medical necessity is established when the patient presents with persistent or recurrent ptosis after a previous surgical intervention, impacting their vision, causing cosmetic concerns, or leading to potential complications like corneal exposure. The documentation must demonstrate an attempt at non-surgical correction (where applicable) and justify the need for revision surgery.
The ophthalmologist or qualified surgeon is responsible for pre-operative assessment, surgical procedure (including incision, muscle adjustment, and closure), and post-operative care.Anesthesiology may be separately reported if applicable.
- Surgery
- Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion) Procedures on the Eyelids
In simple words: The doctor fixes a previous surgery to improve a droopy eyelid. They carefully adjust the eyelid muscles to make the eyelid close normally.
This CPT code encompasses the surgical revision of a prior procedure performed to correct blepharoptosis (drooping eyelid).The surgeon reduces tension on the levator muscle or other supporting structures to improve eyelid position and allow for normal closure.This typically involves an incision at the site of the previous surgery, muscle resection or adjustment, and layered closure with sutures. Modifiers E1-E4 can be used to specify the affected eyelid (left upper, left lower, right upper, right lower).
Example 1: A 60-year-old female patient had a previous ptosis repair that resulted in incomplete correction. The surgeon performs a revision to further adjust the levator muscle, improving eyelid elevation and symmetry., A 45-year-old male patient underwent a ptosis repair several years ago. Due to recurrence of ptosis, a revision is necessary, involving a similar procedure with adjustment to the levator aponeurosis., A 70-year-old female patient with previous ptosis surgery experiences overcorrection resulting in incomplete eyelid closure. A revision is performed to reduce the tension on the levator muscle, restoring normal eyelid function and minimizing the risk of corneal exposure.
* Pre-operative assessment including patient history, physical examination (including assessment of eyelid position and muscle function), and photographic documentation.* Operative report detailing the surgical technique, including specific muscle adjustments made, and materials used.* Post-operative assessment and photographic documentation.* Any relevant diagnostic testing (e.g. imaging studies).
** The surgeon's judgment determines the specific surgical technique required for revision of ptosis surgery.Adequate documentation is crucial for accurate coding and reimbursement. Consult the current CPT manual and payer-specific guidelines for detailed information.
- Revenue Code: P4E (EYE PROCEDURE - OTHER)
- RVU: Information not available in provided sources.Consult the current year's CPT codebook or a relevant medical billing resource for RVU data.
- Global Days: Information not available in provided sources.The global period will vary depending on the extent of the procedure and payer guidelines.
- Payment Status: Active
- Modifier TC rule: The information provided does not specify whether a TC modifier is applicable. Refer to payer-specific guidelines.
- Fee Schedule: Information not available in provided sources.Consult a reliable medical billing database for historical fee schedule data.
- Specialties:Ophthalmology, Plastic Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)