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Background
The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery.
As the umbrella organization for the specialty, ASPS represents 97 percent of 5,000 of the board-certified surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS) and other organizations of specialty societies.
Definitions
Blepharoplasty may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. It may be either reconstructive or cosmetic (aesthetic).
Cosmetic Blepharoplasty
Reconstructive Blepharoplasty
When blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids (ptosis); repair defects caused by trauma or tumor-ablative surgery (ectropian entropian corneal exposure); treat periorbital sequelae of thyroid disease and nerve palsy; or relieve the painful symptoms of blepharospasm, the procedure should be considered reconstructive. This may involve rearrangement of excision of the structures within the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally, a graft of skin or other distant tissues is transplanted to replace deficient eyelid components.
It is the opinion of ASPS that reconstructive blepharoplasty should be compensable by third-party payers. It should be performed only after a specific diagnosis is made, and the indications documented.
Ptosis
Ptosis occurs when the eyelid droops more than is considered normal. This condition may affect one or both eyes and impair vision. Ptosis is usually categorized either as "true ptosis," a lack of normal eyelid support or the presence of excess lid tissue. Ptosis may be present from birth (congenital) or develop with maturity (acquired).
Cosmetic and Reconstructive Surgery
For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989:
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Indication for Reconstructive Blepharoplasty
Pseudoptosis causing visual impairment, ICD-9:
374.33,374.34,368.44,701.8
In this condition, the upper-lid skin becomes
redundant and lax to such an extent that it "hoods" the eye, restricting the
patient's upward gaze and blocking peripheral vision. When the upper-lid skin
rests on the eyelashes, even forward gaze can be impaired. Shin redundancy
(dermatochalasis) and/or muscle laxity is corrected with a reconstructive
upper-lid blepharoplasty that removes excess tissue and restores visual
function. Patients may also develop intermittent swelling of the eyelids
(blepharochalasis), which is often related to allergic reactions and is treated
in a similar fashion.
CPT: 15820, 15821, 15822, 15823, 67930-75
Hooding of the lateral upper eyelids may be aggravated by redundancy and
ptosis of the skin of the lateral forehead and eyebrows. This is an exaggerated
effect of aging. Correction of the eyelid skin redundancy when associated brow
ptosis is untreated may not provide satisfactory results. In these cases, a
browlift with excision of excess forehead or anterior scalp skin may be required
to suspend the brows in a more normal position and relieve the ptosis.
CPT:
15824
True ptosis with dermatochalasis, ICS-9: 374.33
Dermatochalasis (excessive
skin redundancy) may mask the presence of ptosis. The added weight on the upper
lids may aggravate a mild ptotic condition, leading to restricted vision.
Corrections of dermatochalasis are an integral part of ptosis treatment to
restore vision.
CPT: 15820, 15821, 15822, 15823, 67901, 67902, 67903, 67904,
67906, 37908, 67909, 67911
Primary essential (idiopathic) blepharospasm, ICD-9: 333.81,728.9
This
condition is characterized by severe squinting, secondary to uncontrollable
spasms of the periorbital muscles. Occasionally, it can be debilitating.
Treatment includes extended blepharoplasty with wide resection of the
orbicularis oculi muscle complex.
CPT: 15820, 15821, 15822, 15823, 67930-75
Secondary to birth defects, ICD-9:
743.62,743.63,743.64,743.65,744.66
Post-traumatic, ICD-9:
906.0,906.1,906.2,906.3,906.4,906.5
Keloid scar formation, ICD-9:
701.4,709.61
Entropian, ICD-9: 374.01,374.02,374.03
Ectropian, ICD-9:
374.11,374.12,374.13,374.14
These abnormalities may be congenital, a result of injury, or an after-effect of surgery for lesions on the eyelids. Surgery is performed to reconstruct the normal structure of the eyelids using local or distant tissue. If entropian (turned-in lash margins) or extropian (eversion of lids) is left untreated, significant irritative keratitis can lead to cornea erosion. Both upper and lower lids may be affected by these conditions.
In cases of unilateral reconstruction, the opposite eyelid may require
surgery to produce a symmetrical appearance (ICD-9: V51). This additional
procedure should be regarded as reconstructive blepharoplasty.
CPT: 15820,
15821, 15822, 15823, 67921, 67922, 67923, 67924, 67914, 67915, 67916, 67917
Cranial nerve palsy, ICS-9L 351.0,998.2
Partial or complete palsy of the
facial (seventh cranial) nerve or the oculomotor (third cranial) nerve can cause
true ptosis or pseudoptosis from marked periorbital muscle paralysis. Symptoms
such as exposure keratitis and cornea erosion (facial nerve) or visual
restriction (oculomotor nerve) may occur. When lesions involving the temporal
branch of the facial nerve are present, treatment consists of reconstructive
blepharoplasty with or without browlift. Third-nerve palsy may require frontalis
fascial suspension to obtain an adequate eyelid opening.
CPT: 15820, 15821,
15822, 15823
Thyroid disease, ICD-9:
242.0,242.1,242.2,242.3,242.4,242.5,242.6,242.7,242.8,376.21
Symptoms
associated with thyroid disease can include unilateral or bilateral upper-eyelid
retraction and proptosis (protruding eye). Frequently, medical therapy for the
thyroid pathology will resolve these deformities, but occasionally,
reconstructive blepharoplasty is necessary to prevent corneal exposure and
erosion.
CPT: 15820, 15821, 15822, 15823
Documentation
When reconstructive blepharoplasty is performed, the indications for surgery should be documented by the surgeon in the history and physical and reiterated in the operative note. For completeness, using a reliable source for visual-field charting is recommended when visual impairment is involved. A complete eye evaluation may be appropriate in selected cases. Such documentation should qualify a procedure as medically necessary and, therefore, eligible for insurance coverage.
Photographs are usually taken to document pre-operative conditions and aid the surgeon in planning surgery. In some cases, they may record physical signs; however, they do not substantiate symptoms and should only be used by third-party payers in conjunction with less subjective documentation. In circumstances when photographs may be useful to a third-party payer, the plastic surgeon should provide them. The patient, however, must sign a specific release, and confidentiality must be honored. It is the opinion of ASPS that a board-certified plastic surgeon should evaluate all submitted photographs.
Position Statement
It is the position of the American Society of Plastic Surgeons that blepharoplasty is compensable by third-party payers when performed alone of combined with other related procedures for reconstructive purposes.
References
1. Castanares, S. Classification of baggy eyelids. Plast. Reconst. Surg., 59:629, 1977
2. Della Rocca, R.C.;Nesi, F.A.; and Lisman, R.D. (ed) Ophthalmic Plastic Surgery and Reconstructive Surgery, Vol 1 and 2. Washington, D.C.: The C.V.Mosby Col, 1987
3. McCord, C.W.(ed). Aesthetic Plastic Surgery, VOl2 Philadelphia: W. B. Saunders, CO., 1980
4. Tebetts, J.B. Blepharoplasty and browlift. Selected Readings in Plastic Surgery, Vol.5, Number 18. May, 1989.