67901

🩺 CPT 67901: Repair of blepharoptosis using frontalis muscle technique with suture or other material

Short Definition

Repair of blepharoptosis using frontalis muscle technique with suture or other material

Long Definition

CPT code 67901 describes the surgical correction of blepharoptosis (drooping upper eyelid) using the frontalis muscle suspension technique with suture or synthetic material. This procedure is primarily indicated for patients with severe ptosis and poor or absent levator muscle function (typically less than 4-5mm of levator excursion). The technique involves creating a mechanical connection between the upper eyelid tarsus and the frontalis muscle of the forehead, allowing the patient to elevate the eyelid by contracting the frontalis muscle (raising the eyebrow). The procedure uses non-biological materials such as permanent sutures (e.g., Prolene, Mersilene), silicone rods, or other synthetic sling materials. This code is commonly used for congenital ptosis in children with poor levator function, acquired ptosis with severe levator dysfunction, neurogenic ptosis, and myogenic ptosis. The global surgical period is 90 days.

Area of Body

Upper eyelid and forehead structures, including:

• Upper eyelid tarsus (connection point inferiorly)
• Pretarsal and preseptal tissues
• Orbital septum (traversed)
• Frontalis muscle of forehead (attachment point superiorly)
• Subcutaneous tissues of eyelid and forehead
• Supraorbital region
• Eyebrow region
• Skin incisions at lid crease and above brow

Service Components

Included Services:

• Pre-operative measurements and surgical planning
• Marking of incision sites and sling pathway
• Anesthesia administration (local or general - general anesthesia separately billable by anesthesiologist)
• Surgical incision(s):
  • Lid crease incision
  • Small incisions above brow or in forehead
• Dissection to expose tarsus
• Passage of suture or sling material from tarsus through eyelid tissues to frontalis muscle
• Securing suture/material to tarsus and frontalis muscle
• Intraoperative lid height and contour adjustment
• Hemostasis
• Closure of incisions
• Frost suture or lagophthalmos management if needed
• Immediate post-operative care including eye protection
• All routine post-operative care during 90-day global period:
  • Multiple post-operative visits
  • Suture removal
  • Adjustment of lid height if needed (within global)
  • Treatment of routine complications
  • Lubrication management for lagophthalmos
• Standard surgical supplies

Excludes:

• Frontalis suspension using autologous fascia lata (use 67902 instead - different code)
• Levator resection/advancement procedures (use 67903 or 67904 - for better levator function)
• Superior rectus muscle transfer technique (use 67906)
• Conjunctivotarso-Müller resection/Fasanella-Servat (use 67908 - minimal ptosis)
• Correction of overcorrection (use 67909)
• Upper lid blepharoplasty for dermatochalasis (use 15822 or 15823)
• Brow ptosis repair (use 67900)
• Lower eyelid procedures
• Ectropion or entropion repair (67914-67924)
• Separate anesthesia provider charges (billable separately)
• Pre-operative testing beyond standard evaluation

Unbundled/Separately Billable:

• Pre-operative comprehensive eye examination with modifier 57 if decision for surgery made
• Unrelated E/M services during global period (modifier 24)
• Unrelated procedures during global period (modifier 79)
• Anesthesia services by separate provider
• Concurrent procedures on fellow eye with separate diagnosis

RVU Information

Work RVU (wRVU): 9.79
Facility Total RVU: Approximately 14.28
Non-Facility Total RVU: Approximately 18.92
Global Days: 090 (90-day global surgical period)
Medicare Status: Active/Payable when medical necessity documented
2026 Medicare National Average:

• Facility: Approximately $462-495
• Non-Facility: Approximately $612-655
  (Varies by geographic locality and MAC)

RVU Comparison to Related Codes:

• 67901 (frontalis with suture): 9.79 wRVU
• 67902 (frontalis with fascia): 12.64 wRVU (higher due to fascia harvesting)
• 67903 (levator internal): 9.08 wRVU
• 67904 (levator external): 8.84 wRVU
• Frontalis techniques generally have higher RVUs due to complexity

HCC Status

Not Applicable - HCC coding applies only to ICD-10 diagnosis codes, not CPT procedure codes

Assistant Surgeon Status

Assistant Payable: Yes, with restrictions

Medicare Assistant Surgeon Policy:

• CPT 67901 may qualify for assistant surgeon payment
• Medicare designation: “Assistant surgeon may be paid” (varies by MAC)
• Payment allowed when medical necessity documented
• Typical reimbursement: 16% of surgeon’s allowed amount for physician
• Must document why assistant was medically necessary

Justification for Assistant Surgeon:
More likely approved for:

• Bilateral procedures performed simultaneously
• Complex revision cases with scarring
• Pediatric cases requiring additional assistance for positioning/cooperation
• Patients with bleeding disorders or anticoagulation
• Combined procedures requiring extended operative time
• Difficult anatomy or prior failed procedures
• Surgeon factors (training assistant, medical necessity)

Applicable Assistant Surgeon Modifiers:

• Modifier 80: Assistant surgeon (physician) - 16% payment
• Modifier 81: Minimum assistant surgeon (rarely used) - 16% payment
• Modifier 82: Assistant surgeon when qualified resident unavailable (teaching hospitals) - 16% payment
• Modifier AS: Physician assistant, nurse practitioner, or CNS as assistant - 13.6% payment (85% of 16%)

Documentation Requirements for Assistant:

• Operative report must document assistant’s participation
• Specific tasks performed: retraction, passing sutures, securing sling material, hemostasis
• Medical necessity statement in operative report or cover letter
• Primary surgeon attestation of necessity

Payer Variations:

• Medicare: May allow with appropriate documentation
• Medicare Advantage: Often requires prior authorization for assistant
• Commercial payers: Variable; many have restrictive policies
• Some payers never allow assistants for eyelid procedures
• Pre-authorization strongly recommended

Common Modifiers

Modifier	Description	Usage Frequency	Reimbursement Impact	Notes
50	Bilateral procedure	High	150% of unilateral fee	Very common for congenital ptosis
E1	Upper left eyelid	Moderate	100% first eye, 50% second	Alternative to modifier 50
E3	Upper right eyelid	Moderate	100% first eye, 50% second	Alternative to modifier 50
22	Increased procedural services	Low-Moderate	20-50% increase if justified	Revision, severe scarring, complex anatomy
51	Multiple procedures	Low-Moderate	50% reduction secondary procedure	When combined with other procedures
54	Surgical care only	Low	~70% of global fee	Transfer of care
55	Postoperative management only	Low	~10% of global fee	Transfer of care
56	Preoperative management only	Low	~20% of global fee	Transfer of care
57	Decision for surgery	Common	Allows E/M same day as major surgery	Pre-op visit with decision
58	Staged procedure	Moderate	100% payment for planned staged	When bilateral done in stages
59	Distinct procedural service	Low	Bypasses NCCI edits	Separate procedure when appropriate
76	Repeat procedure by same physician	Low	Reduced payment during global	Adjustment for undercorrection
78	Return to OR for complication	Low	~70% payment	Complication during global
79	Unrelated procedure during global	Low	100% if truly unrelated	New global period
80	Assistant surgeon	Low	16% (for assistant’s claim)	Physician assistant at surgery
AS	PA/NP/CNS assistant	Low	13.6% (for assistant’s claim)	Non-physician assistant
LT	Left side	Alternative	Alternative to E1	Some payers prefer
RT	Right side	Alternative	Alternative to E3	Some payers prefer

Critical Modifier Notes:

• Bilateral procedures: Very common in congenital ptosis; use modifier 50 or E1/E3
• Modifier 50 payment: 150% of unilateral (not 200%)
• Modifier 22: Requires detailed documentation of significantly increased work
• Modifier 58: Use when staging bilateral procedure (e.g., one eye heals before doing second)

Common Associated CPT Codes

CPT Code	Description	Relationship to 67901	Billing Considerations
67902	Frontalis suspension with autologous fascia	Alternative to 67901	Use instead if fascia harvested; higher RVU
67903	Levator resection, internal approach	Alternative procedure	For better levator function cases
67904	Levator resection, external approach	Alternative procedure	For moderate ptosis with adequate levator
67906	Superior rectus muscle technique	Alternative for severe cases	Complex procedure for severe ptosis
67908	Conjunctivotarso-Müller resection	Alternative for mild ptosis	Minimal ptosis with good levator
67909	Reduction of overcorrection	Related follow-up	If overcorrection occurs
15822	Upper lid blepharoplasty, skin only	May be combined	Separate diagnosis required
15823	Upper lid blepharoplasty with fat	May be combined	NCCI bundles into 67901; need modifier
67900	Brow ptosis repair	May be combined	If concurrent brow ptosis
92002-92014	Eye examination codes	Pre-operative	Modifier 57 if decision for surgery
92018	Ophthalmological examination under anesthesia	Pediatric cases	If exam under anesthesia needed
92060	Sensorimotor exam	Pre/post-operative	Assess ocular motility
92081-92083	Visual field testing	Pre-operative	Functional impairment documentation
67840	Excision eyelid lesion	May be combined	If separate lesion present
00103	Anesthesia for eyelid procedures	Related anesthesia	Billed by anesthesiologist/CRNA
20926	Tissue grafts, fascia	If fascia used	May be bundled; check if separate

Common Procedure Combinations:

Bilateral Frontalis Suspension:

• 67901-50 (bilateral) - Most common billing method
• OR 67901-E3, 67901-E1 (separate lines)

Frontalis Suspension + Blepharoplasty:

• 67901 (primary code)
• 15823-51 (if fat removed) or 15822-51 (skin only)
• Note: NCCI bundles 15823 into 67901; may need modifier 59 with strong documentation

Staged Bilateral Procedure:

• First eye: 67901-RT
• Second eye (later date): 67901-58-LT (planned staged procedure)

Code Tree/Hierarchy

CPT Manual Section: Surgery (10001-69990)
Anatomic Subsection: Eye and Ocular Adnexa (65091-68899)
Major Category: Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion) (67900-67924)
Subcategory: Blepharoptosis Repair (67901-67909)
Specific Technique: Frontalis Suspension with Suture/Synthetic Material
Code: 67901

Ptosis Repair Code Family:

Blepharoptosis Repair Procedures (67901-67909)
├── Frontalis Suspension Techniques (Severe Ptosis, Poor Levator)
│   ├── 67901 - Frontalis with suture or synthetic material ◄ Current Code
│   └── 67902 - Frontalis with autologous fascia lata
│
├── Levator Repair Techniques (Moderate Ptosis, Adequate Levator)
│   ├── 67903 - Levator resection or advancement, internal approach
│   └── 67904 - Levator resection or advancement, external approach
│
├── Alternative Techniques
│   ├── 67906 - Superior rectus muscle technique (severe ptosis)
│   └── 67908 - Conjunctivotarso-Müller resection (minimal ptosis)
│
└── Revision/Correction
    └── 67909 - Reduction of overcorrection of ptosis

Code Selection Algorithm for Ptosis Repair:

Patient with Blepharoptosis?
├── Assess Levator Function
│   ├── Levator Function < 4-5mm (Poor/Absent)
│   │   ├── Use autologous fascia lata (gold standard, especially children)
│   │   │   └── 67902 (Frontalis with fascia)
│   │   └── Use suture or synthetic sling material
│   │       └── 67901 ◄ Current Code
│   │
│   ├── Levator Function 5-10mm (Fair/Moderate)
│   │   ├── Internal approach preferred
│   │   │   └── 67903 (Levator resection, internal)
│   │   └── External approach (surgeon preference/revision)
│   │       └── 67904 (Levator resection, external)
│   │
│   ├── Levator Function > 10mm with Minimal Ptosis (1-2mm)
│   │   └── 67908 (Müller muscle-conjunctival resection)
│   │
│   └── Extremely Severe Ptosis, Failed Prior Surgery
│       └── 67906 (Superior rectus muscle transfer)
│
└── Post-operative Overcorrection?
    └── 67909 (Reduction of overcorrection)

Related Codes in Other Categories:

Upper Eyelid Surgery Codes
├── Eye and Ocular Adnexa Section
│   ├── 67900 - Brow ptosis repair (different from eyelid ptosis)
│   ├── 67901-67909 - Ptosis repair ◄ Current family
│   ├── 67911-67912 - Lid retraction repair
│   └── 67914-67924 - Ectropion/entropion
│
└── Integumentary Section
    ├── 15822 - Upper bleph, skin only (dermatochalasis)
    └── 15823 - Upper bleph with fat (dermatochalasis + fat)

Key Differences Between Frontalis Techniques:

• 67901: Uses suture (Prolene, Mersilene, Supramid) or synthetic rods (silicone)
• 67902: Uses autologous fascia lata harvested from thigh
• 67902 higher RVU (12.64 vs 9.79) due to fascia harvesting
• 67902 often preferred for pediatric congenital ptosis (lower infection/extrusion risk)
• 67901 faster procedure, no donor site morbidity

Coding Examples

Example 1: Bilateral Congenital Ptosis in Child

Patient Presentation: 4-year-old male with severe bilateral congenital ptosis since birth. Chin-up head posture to see. Parents report he tilts head back constantly.

Pre-operative Assessment:

• Severe bilateral ptosis: MRD1 -1mm OD, 0mm OS (pupils partially covered)
• Levator function: 2mm OD, 3mm OS (severely reduced; normal >12mm)
• No Bell’s phenomenon (high risk for exposure keratopathy)
• Chin-up head position for visual axis
• Compensatory frontalis overaction
• Visual acuity: Age-appropriate with correction
• No amblyopia detected

Diagnosis: Bilateral congenital blepharoptosis with poor levator function

Surgical Planning:

• Frontalis suspension required due to poor levator function (<4mm)
• Consider 67902 (fascia) vs 67901 (synthetic) - chose Supramid suture for ease and family preference
• Plan bilateral simultaneous surgery

Surgery Performed: Bilateral frontalis suspension with Supramid suture

• General anesthesia
• Bilateral lid crease incisions exposing tarsus
• Small stab incisions above brows bilaterally
• Supramid suture passed from tarsus through eyelid tissues to frontalis muscle in double-rhomboid pattern
• Sutures secured to anterior surface of tarsus
• Sutures passed through orbicularis and secured to frontalis muscle and periosteum
• Lid height adjusted intraoperatively to slight overcorrection (accounts for settling)
• Target MRD1: 4mm OU
• Closure of lid crease incisions with 6-0 plain gut
• Frost sutures placed for nocturnal lagophthalmos protection
• Lubrication protocol initiated

Post-operative Plan:

• Aggressive lubrication (drops hourly while awake, ointment at night)
• Frost sutures for 1 week
• Taping lids at night for lagophthalmos
• Follow-up: Day 1, Week 1 (frost suture removal), Week 2, Month 1, Month 3, Month 6, Year 1
• Monitor for exposure keratopathy
• Adjust lid height if needed (within global period)

Coding:

• 67901-50 - Repair of blepharoptosis, frontalis muscle technique with suture, bilateral

Diagnoses:

• H02.421 - Myogenic ptosis of right upper eyelid
• H02.422 - Myogenic ptosis of left upper eyelid
• Q10.0 - Congenital ptosis (if specifically documenting congenital nature)

Supporting Documentation:

• Pre-operative photographs showing severe ptosis and chin-up posture
• Measurements of MRD1 and levator function
• Documentation of levator function <4mm supporting frontalis technique
• Operative report with detailed technique description
• Post-operative care plan for lagophthalmos management

Reimbursement: 150% of unilateral allowable with modifier 50.

Example 2: Unilateral Acquired Ptosis from Levator Dehiscence

Patient: 72-year-old female with progressive right upper lid drooping over 2 years, worse in evening. No history of trauma or surgery.

Pre-operative Findings:

• Right ptosis: MRD1 0.5mm OD (normal left: MRD1 4mm)
• Levator function: 4mm OD (poor), 14mm OS (normal left)
• High lid crease OD (sign of levator dehiscence)
• Good Bell’s phenomenon
• Superior visual field defect OD improved with manual elevation
• Diagnosis: Acquired aponeurotic ptosis with poor levator function right eye

Surgical Decision:

• Levator function only 4mm (borderline for levator surgery)
• Surgeon chooses frontalis suspension for more reliable result
• Unilateral procedure only (left side normal)

Surgery: Right frontalis suspension with Mersilene mesh

• Local anesthesia with sedation
• Right lid crease incision
• Mersilene mesh passed from tarsus to frontalis
• Lid elevated to match left side contour
• Closure

Coding:

• 67901-E3 (or 67901-RT) - Frontalis suspension, right upper lid only

Diagnoses:

• H02.411 - Mechanical ptosis of right upper eyelid (aponeurotic ptosis)
• H53.461 - Visual field defect, upper right

Medical Necessity: Functional impairment with visual field defect; poor levator function precludes standard levator repair.

Example 3: Bilateral Ptosis with Concurrent Dermatochalasis

Patient: 68-year-old male with moderate bilateral ptosis from levator dehiscence PLUS severe dermatochalasis with fat herniation.

Pre-operative Assessment:

• Ptosis: MRD1 1.5mm OU
• Levator function: 5mm OU (poor, but borderline)
• Severe dermatochalasis with skin touching lashes
• Prominent fat herniation medially
• Visual fields: Superior defects from both ptosis AND dermatochalasis
• Assessment: Both conditions contribute to visual impairment

Surgical Planning:

• Needs both ptosis repair AND blepharoplasty
• Frontalis suspension chosen due to marginal levator function
• Blepharoplasty for excess skin/fat

Surgery:

1. Bilateral frontalis suspension with silicone rods
2. Bilateral upper lid blepharoplasty with fat excision via same lid crease incisions

Coding:

• 67901-50 - Frontalis suspension, bilateral (PRIMARY code)
• 15823-51 - Blepharoplasty with fat removal (SECONDARY code with modifier 51)

Alternative (if payer allows):

• 67901-E3 - Frontalis right
• 67901-E1 - Frontalis left
• 15823-59-E3 - Bleph right (modifier 59 to bypass NCCI)
• 15823-59-E1 - Bleph left (modifier 59)

Diagnoses:

• H02.412 - Mechanical ptosis, left upper eyelid
• H02.411 - Mechanical ptosis, right upper eyelid
• H02.33 - Dermatochalasis of bilateral upper eyelids
• H53.463 - Bilateral visual field defects, upper

Critical Documentation:

• Must document TWO separate conditions:
  1. Blepharoptosis from levator dysfunction (needs 67901)
  2. Dermatochalasis with fat herniation (needs 15823)
• Document that BOTH conditions present and BOTH procedures necessary
• Separate measurements supporting each diagnosis
• Visual field defects from both conditions
• Cannot correct one without addressing the other

NCCI Edit Warning:

• 15823 bundles into 67901 (Column 1/Column 2 edit)
• Modifier 51 or 59 required
• Strong documentation of medical necessity for BOTH procedures essential
• Some payers may deny 15823 even with modifier
• Prior authorization strongly recommended

Example 4: Revision of Failed Previous Ptosis Surgery

Patient: 45-year-old female with recurrent right ptosis 3 years after levator resection. Previous surgery failed due to poor levator function.

Pre-operative Findings:

• Recurrent severe ptosis: MRD1 -0.5mm OD
• Levator function: 3mm (poor, likely from previous surgery damage)
• Significant scarring in lid crease
• High lid crease from previous external levator approach
• Left eye normal (no prior surgery)

Surgical Decision:

• Frontalis suspension required due to failed levator repair and poor function
• Revision surgery more complex due to scarring
• Need to work through scar tissue

Surgery: Revision right frontalis suspension

• Local anesthesia with sedation
• Extensive scar tissue encountered
• Required sharp dissection through adhesions
• Previous levator advancement identified and left in place
• Silicone rod passed with difficulty through scarred tissue
• Secured to tarsus and frontalis
• Operative time: 95 minutes (typical 45-60 minutes)
• More complex due to distorted anatomy

Coding:

• 67901-22-RT - Frontalis suspension with modifier 22 for increased complexity

Modifier 22 Documentation:

• Detailed operative report:
  • “Revision ptosis surgery significantly more complex than primary procedure”
  • “Extensive scar tissue from previous external levator resection encountered”
  • “Required meticulous sharp dissection through adhesions”
  • “Distorted anatomy from previous surgery made tissue plane identification difficult”
  • “Operative time 95 minutes vs typical 45-60 minutes (58% increase)”
  • “Increased risk of complications due to scarring”
• Cover letter to payer:
  • “Request 35% additional reimbursement for significantly increased complexity”
  • Explain previous surgery, scarring, increased time, technical difficulty

Diagnoses:

• H02.411 - Mechanical ptosis, right upper eyelid, recurrent
• L90.5 - Scar conditions and fibrosis of skin

Expected Reimbursement: Base payment plus 25-40% if modifier 22 approved.

Example 5: Congenital Ptosis with Marcus Gunn Jaw-Winking

Patient: 5-year-old child with congenital right ptosis and jaw-winking syndrome (synkinetic ptosis).

Pre-operative Findings:

• Right congenital ptosis: MRD1 0mm
• Levator function: 3mm (poor)
• Marcus Gunn jaw-winking: Lid elevates 4mm with jaw movement (chewing, opening mouth)
• Amblyopia screening: Mild amblyopia right eye
• Left eye normal

Diagnosis: Congenital blepharoptosis with aberrant regeneration (Marcus Gunn phenomenon)

Surgical Plan:

• Two-stage procedure recommended:
  1. Levator excision to eliminate synkinesis
  2. Frontalis suspension to provide lid elevation
• Due to complexity, may stage procedures or do simultaneously

Surgery Performed (Single Stage):

• Levator muscle identified and excised (to eliminate jaw-winking)
• Frontalis suspension with Supramid suture performed same setting
• Lid elevated to appropriate height

Coding Consideration:

• 67901-RT - Frontalis suspension, right

Note: Levator excision typically considered part of the overall ptosis repair in this complex scenario; not separately coded unless clearly documented as distinct procedure with significant additional work.

Alternative if truly separate and staged:

• If levator excision performed first encounter and frontalis later: Code each encounter separately

Diagnoses:

• Q10.0 - Congenital ptosis
• Q07.8 - Other specified congenital malformations of nervous system (for Marcus Gunn)
• H53.031 - Amblyopia suspect, right eye

Special Considerations:

• Complex congenital anomaly
• Higher risk procedure
• May qualify for modifier 22 if significantly more complex
• Pediatric anesthesia separately billable

Example 6: Bilateral Myasthenia Gravis Ptosis

Patient: 55-year-old female with myasthenia gravis, severe bilateral ptosis worsening throughout day despite medical management.

Pre-operative Assessment:

• Bilateral ptosis worse in evening: MRD1 0mm OU late day
• Levator function: 2mm OU (severely reduced)
• Fluctuating ptosis characteristic of myasthenia
• On pyridostigmine and prednisone, still symptomatic
• Neurologist cleared for surgery
• Patient counseled on higher complication risk (lagophthalmos, exposure)

Surgery: Bilateral frontalis suspension with adjustable sutures

• Supramid suture technique
• Conservative elevation initially (to avoid overcorrection/exposure given MG risk)
• Plan for possible adjustment

Coding:

• 67901-50 - Bilateral frontalis suspension

Diagnoses:

• G70.00 - Myasthenia gravis without (acute) exacerbation
• H02.422 - Myogenic ptosis, left upper eyelid
• H02.421 - Myogenic ptosis, right upper eyelid

Special Documentation:

• Document myasthenia gravis as underlying cause
• Document medical optimization prior to surgery
• Document patient counseling regarding increased risks
• Post-op plan for aggressive lubrication due to lagophthalmos risk

Medical Necessity: Medically necessary when ptosis causes functional impairment despite maximal medical management of MG.

Documentation Requirements

Pre-operative Documentation Required:

Clinical History:

• Chief complaint: Drooping eyelid, visual obstruction, difficulty seeing
• Duration and progression
• Congenital vs acquired
• Variability (worse when tired, fluctuating)
• Impact on vision and daily activities
• Previous treatments or surgeries
• Associated symptoms (diplopia, amblyopia risk in children)
• Medical history: Myasthenia gravis, neurologic conditions, prior trauma
• Family history if congenital

Physical Examination - Critical Measurements:

• Margin-reflex distance (MRD1): Distance from corneal light reflex to upper lid margin
  • Normal: 4-5mm
  • Mild ptosis: 3-3.5mm
  • Moderate ptosis: 2-2.5mm
  • Severe ptosis: <2mm or negative
• Levator function: Excursion of lid from downgaze to upgaze with frontalis muscle blocked
  • Excellent: >12mm
  • Good: 8-11mm
  • Fair: 5-7mm
  • Poor: <4-5mm
  • Code 67901 typically used when levator function <4-5mm
• Lid crease height (high crease suggests aponeurotic ptosis)
• Bell’s phenomenon (protective reflex; assess lagophthalmos risk)
• Pupil position relative to lid (central vs superior)
• Presence of Marcus Gunn jaw-winking (synkinesis)
• Orbicularis function
• Corneal sensation
• Assessment for dermatochalasis or other concurrent conditions
• Fellow eye measurements for comparison
• Compensatory mechanisms (chin-up position, frontalis overaction, brow elevation)

Objective Testing:

• Visual acuity
• Pupil examination
• Motility assessment (especially in children - rule out superior rectus weakness)
• Phenylephrine test (Müller muscle function - helps differentiate ptosis types)
• Ice test if myasthenia suspected
• Visual field testing if functional obstruction claimed
• Amblyopia screening in children
• Pre-operative photographs (REQUIRED):
  • Front view primary gaze
  • Upgaze and downgaze
  • Lateral views both sides
  • Photos should show ptosis severity and levator function

Indication for Frontalis Suspension (67901) vs Other Techniques:
Document why frontalis chosen:

• Poor levator function (<4-5mm) is PRIMARY indication
• Levator resection not feasible due to inadequate muscle function
• Revision after failed levator surgery
• Congenital ptosis with minimal levator function
• Neurogenic or myogenic ptosis (MG, oculomotor nerve palsy, CPEO)
• Marcus Gunn jaw-winking (may need levator excision + frontalis)

Choice of Material (67901 vs 67902):
Document material selection:

• Suture or synthetic material → 67901
• Autologous fascia lata → 67902 (different code, higher RVU)
• Rationale for material choice

Informed Consent Documentation:
Discuss and document:

• Lagophthalmos (incomplete lid closure) expected
• Need for aggressive lubrication
• Risk of exposure keratopathy
• Possible need for revision surgery
• Asymmetry risk
• Scarring
• Infection risk
• Under or overcorrection possibility
• Alternative techniques discussed

Operative Report Must Include:

Standard Elements:

• Patient identification, date of service
• Pre-operative diagnosis: Blepharoptosis with poor levator function (specify etiology)
• Post-operative diagnosis: Same
• Procedure name: Repair of blepharoptosis, frontalis muscle technique with [specify material: Supramid/Prolene/Mersilene/silicone rod]
• Surgeon, assistants, anesthesia type
• Indication for surgery

Detailed Procedure Description Must Document:

• Patient positioning and preparation
• Anesthesia type and dosage
• Marking of lid crease incision and brow incisions/stab incisions
• Lid crease incision made and dissection to tarsus
• Exposure of anterior tarsal surface
• Creation of tunnel or pathway from tarsus through eyelid tissues to frontalis region
• Type and configuration of sling material:
  • Single vs double rhomboid pattern
  • Suture size and type
  • Silicone rod specifications if used
• Method of securing material to tarsus (sutures to anterior tarsus)
• Passage of material through eyelid tissues (subcutaneous, preseptal, or other plane)
• Small incisions above brow for material passage
• Securing material to frontalis muscle and/or periosteum
• Intraoperative adjustment of lid height
• Target MRD1 achieved (specify measurement)
• Contour and symmetry assessment
• Hemostasis method
• Closure technique (lid crease and brow incisions)
• Frost suture placement if used for lagophthalmos
• Dressing applied
• Patient condition
• Estimated blood loss
• Complications if any

Key Documentation for Code 67901:

• Must state “frontalis muscle technique”
• Must specify material used: suture OR synthetic material (not fascia - that’s 67902)
• Must document passage from tarsus to frontalis
• Must document securing to both tarsus and frontalis

Post-operative Documentation:
All visits during 90-day global period:

• Lid position and symmetry
• MRD1 measurements
• Lagophthalmos assessment
• Corneal status (exposure keratopathy watch)
• Lubrication compliance
• Any adjustments made (within global)
• Suture removal
• Complications and treatment
• Final outcome assessment

Billing Guidelines and Best Practices

Global Surgical Package (90-Day Global Period):

Included in 67901 Payment:

• Pre-operative visit on day of or day before surgery (unless decision visit with modifier 57)
• Intraoperative services
• All post-operative visits for 90 days related to surgery:
  • Multiple visits for lid position assessment
  • Suture removal (lid crease and frost sutures)
  • Adjustment of lid height if needed within global
  • Treatment of routine complications (minor infections, suture irritation)
  • Lubrication management
  • Lagophthalmos counseling and management
• Standard surgical supplies

NOT Included (Separately Billable):

• E/M visit where decision for surgery made (use modifier 57 if within 1 day of surgery)
• Pre-operative testing (visual fields, photos - if billed separately)
• Unrelated E/M services during global period (use modifier 24)
• Unrelated procedures during global period (use modifier 79)
• Anesthesia services by separate provider (anesthesiologist/CRNA bills separately)
• Major revision surgery (return to OR for complication with modifier 78, or for overcorrection outside global period)

Bilateral Procedure Billing:

Method 1 (Preferred): Modifier 50

• Code: 67901-50
• Payment: 150% of unilateral allowable
• Single line item on claim
• Most efficient and preferred by most payers

Method 2: Anatomic Modifiers

• Line 1: 67901-E3 (right) = 100% payment
• Line 2: 67901-E1 (left) = 50% payment (automatic reduction)
• Total: 150% of unilateral allowable
• Two line items on claim

Important: Do NOT use both modifier 50 AND E1/E3 together

Staged Bilateral Procedures:
When performing eyes on different dates:

• First eye: 67901-RT (or E3) = 100% payment
• Second eye later: 67901-58-LT (or 58-E1) = 100% payment with modifier 58
• Modifier 58 indicates planned staged procedure
• Allows full payment for second eye (not reduced to 50%)
• Must document prospective plan to stage
• Each surgery starts new 90-day global period

Medicare Coverage Criteria:

Covered When:

• Functional visual impairment from ptosis documented
• Symptoms affecting daily activities
• Levator function poor (<4-5mm) supporting frontalis technique
• Conservative management failed or not applicable
• Ptosis causing visual axis obstruction
• Children: Risk of amblyopia
• Medical necessity clearly documented

Typical Coverage Scenarios:

• Congenital ptosis with poor levator function
• Acquired ptosis with levator dehiscence and poor function
• Neurogenic ptosis (oculomotor nerve palsy, myasthenia gravis)
• Myogenic ptosis (chronic progressive external ophthalmoplegia, mitochondrial myopathy)
• Traumatic ptosis with levator damage
• Failed previous levator surgery
• Marcus Gunn jaw-winking syndrome

NOT Covered (Typically):

• Purely cosmetic ptosis correction (minimal functional impact)
• Adequate levator function where levator resection more appropriate
• Patient refuses frontalis technique when it’s indicated
• Cosmetic preference for “more open” appearance without medical necessity

Prior Authorization:

• Medicare: Usually not required but varies by MAC
• Medicare Advantage: Often DOES require prior authorization
• Commercial payers: Variable; many require authorization
• Submit with authorization request:
  • Clinical notes with measurements (MRD1, levator function)
  • Pre-operative photographs
  • Visual field testing if claiming functional obstruction
  • Explanation of why frontalis technique chosen over levator surgery

Modifier 22 for Increased Complexity:

When to Use:

• Revision surgery with extensive scarring
• Complex congenital anomalies (Marcus Gunn requiring levator excision)
• Significant anatomic abnormalities
• Complicated medical conditions increasing surgical risk/time
• Operative time increased 50% or more
• Significantly more difficult than typical case

Documentation Required:

1. Detailed operative report explicitly documenting:
   • Specific increased complexity factors
   • Additional time required (document time, compare to typical)
   • Technical difficulties overcome
   • Increased risk factors
   • Why case significantly more complex than standard 67901
2. Cover letter to payer:
   • Summarize increased complexity
   • Request specific percentage increase (typically 20-50%)
   • Compare to typical case
   • Justify additional reimbursement
3. Supporting documents:
   • Prior operative reports if revision
   • Medical records documenting complex diagnosis

Success Rate: Variable; requires compelling documentation of truly increased work.

NCCI Edits - Critical Bundling Rules:

Codes That Bundle INTO 67901 (Column 2 codes):

• 15822 (upper bleph, skin only)
• 15823 (upper bleph with fat)
• These are bundled; 67901 is Column 1 code

To Bill Together:

• Use modifier 59 or appropriate X modifier (XE, XS, XP, XU)
• Must document:
  • TWO separate diagnoses (ptosis AND dermatochalasis)
  • Both conditions present independently
  • Both procedures medically necessary
  • Cannot address one without the other
• Strong documentation essential
• Prior authorization recommended
• Some payers deny combination even with modifier

Codes That Can Be Billed Together:

• 67900 (brow ptosis) - different anatomic structure
• 67909 (reduction of overcorrection) - different encounter typically
• Examination codes with modifier 57 (decision visit)
• Visual field testing (pre-operative)

Multiple Procedure Reduction:
When billing 67901 with other procedures:

• 67901 typically primary code (highest RVU among eyelid procedures except 67902)
• Secondary procedures reduced 50% with modifier 51
• Check payer-specific multiple procedure rules

Assistant Surgeon Billing:
When assistant surgeon used:

• Surgeon bills: 67901 (or with appropriate modifiers)
• Assistant bills: 67901-80 (or AS if PA/NP/CNS)
• Assistant receives 16% of surgeon’s allowed (physician)
• Assistant receives 13.6% if PA/NP/CNS (85% of 16%)
• Must document medical necessity in operative report

Cosmetic vs Functional - Compliance:

Functional (Covered):

• Visual axis obstruction
• MRD1 at or below pupil margin
• Documented visual impairment
• Levator function poor (<4-5mm)
• Symptoms affecting daily activities
• Children: Amblyopia risk

Cosmetic (Not Covered):

• Aesthetic preference for more “open” eye
• Minimal ptosis with no functional impact
• Adequate levator function (should use different technique)
• No symptoms
• Normal visual function

Critical Compliance Points:

• Never upcode cosmetic as functional
• Document medical necessity clearly
• Measurements must support severity
• Levator function must support frontalis technique choice
• Photographs essential
• Informed consent documents lagophthalmos and risks

Audit Risk Factors:

• High volume of ptosis surgeries
• Always billing bilateral
• Frequently combining with blepharoplasty
• Inadequate documentation of levator function
• Missing photographs
• Template documentation lacking individualization
• Billing 67901 when levator function adequate for levator resection

Best Practices for Compliance:

• Document MRD1 and levator function every case
• Take standardized pre-operative photographs
• Individualize documentation (avoid templates)
• Document rationale for frontalis technique selection
• Clearly state material used (suture/synthetic vs fascia)
• When combining procedures, document separate medical necessity
• Follow up appropriately during global period
• Code accurately based on technique actually performed

Clinical Indications and Diagnosis Codes

Primary Diagnoses for Frontalis Suspension:

Congenital Ptosis:

• Q10.0 - Congenital ptosis (most common for pediatric cases)
• Usually associated with poor levator development
• Classic indication for frontalis suspension

Acquired Ptosis Types:

Mechanical Ptosis:

• H02.411 - Mechanical ptosis of right upper eyelid
• H02.412 - Mechanical ptosis of left upper eyelid
• H02.413 - Mechanical ptosis of bilateral upper eyelids
• Includes aponeurotic ptosis, levator dehiscence

Myogenic Ptosis:

• H02.421 - Myogenic ptosis of right upper eyelid
• H02.422 - Myogenic ptosis of left upper eyelid
• H02.423 - Myogenic ptosis of bilateral upper eyelids
• Includes myasthenia gravis, CPEO, muscular dystrophy

Neurogenic Ptosis:

• H02.431 - Paralytic ptosis of right upper eyelid
• H02.432 - Paralytic ptosis of left upper eyelid
• H02.433 - Paralytic ptosis of bilateral upper eyelids
• Includes oculomotor nerve palsy

Unspecified Ptosis:

• H02.401 - Unspecified ptosis of right eyelid
• H02.402 - Unspecified ptosis of left eyelid
• H02.403 - Unspecified ptosis of bilateral eyelids
• Use when specific etiology unclear

Related/Supporting Diagnoses:

Underlying Systemic Conditions:

• G70.00 - Myasthenia gravis without exacerbation
• G70.01 - Myasthenia gravis with exacerbation
• H49.00-H49.03 - Third nerve palsy (oculomotor nerve)
• G71.0 - Muscular dystrophy
• H49.41-H49.43 - Chronic progressive external ophthalmoplegia (CPEO)
• Q07.8 - Marcus Gunn jaw-winking syndrome

Functional Impact:

• H53.461 - Visual field defect, upper right
• H53.462 - Visual field defect, upper left
• H53.463 - Bilateral visual field defects, upper
• H53.031-H53.033 - Amblyopia suspect (pediatric cases)

Concurrent Conditions (If Addressing Simultaneously):

• H02.31-H02.33 - Dermatochalasis (if concurrent blepharoplasty)
• H02.841-H02.842 - Dermatochalasis of eyebrow (if concurrent brow lift)

Post-operative Complications:

• H02.20x - Lagophthalmos (expected after frontalis)
• H16.xx - Keratitis (if exposure keratopathy develops)
• T85.79XA - Infection and inflammatory reaction due to other internal prosthetic devices (if sling infection)
• L90.5 - Scar conditions (if scarring issue)

Incorrect Diagnosis Coding:

• Do NOT use dermatochalasis codes alone for ptosis (H02.3x without H02.4x)
• Do NOT use brow ptosis codes (H02.84x) for eyelid ptosis
• Must use specific ptosis codes (H02.40x-H02.43x or Q10.0)

Diagnosis Documentation Tips:

• Specify laterality (right, left, bilateral)
• Use most specific code available
• Include underlying systemic diagnosis if applicable
• Document severity in clinical notes even if not captured in ICD-10 code
• For congenital ptosis, use Q10.0 as primary; may add H02.4x for laterality specificity