67908

🩺 CPT 67908: Repair of Blepharoptosis Using Conjunctivo-tarso-Müller’s muscle-levator resection

Short Definition

Repair of blepharoptosis using conjunctivo-tarso-Müller’s muscle-levator resection (e.g., Fasanella-Servat type)

Long Definition

CPT code 67908 describes the surgical correction of mild to moderate blepharoptosis (drooping upper eyelid) using an internal (posterior) approach that involves resection of the conjunctiva, tarsus, Müller’s muscle, and sometimes a small amount of levator aponeurosis. This procedure is commonly known as the Fasanella-Servat operation or Müller’s muscle-conjunctival resection (MMCR). The technique is performed entirely through the posterior surface of the eyelid without external skin incisions, making it an excellent option for patients with minimal to moderate ptosis (typically 1-3mm) and good levator function (usually greater than 10mm). The procedure is particularly useful when the phenylephrine test is positive, indicating that Müller’s muscle has good residual function. The surgery involves everting the upper eyelid, clamping the tissues to be resected, excising a measured strip of conjunctiva, tarsus, and Müller’s muscle, and then suturing the cut edges together. Because there are no external incisions, recovery is typically faster with less visible scarring compared to external ptosis repair techniques. The global surgical period is 90 days.

Area of Body

Upper eyelid - posterior (internal) surface, specifically:

• Palpebral conjunctiva (mucous membrane lining inner eyelid)
• Superior tarsus (firm fibrous tissue providing eyelid structure)
• Müller’s muscle (sympathetically innervated smooth muscle that assists lid elevation)
• Levator aponeurosis (may include small amount in traditional Fasanella-Servat; modern MMCR spares levator)
• Superior tarsal border region
• Superior conjunctival fornix

Structures NOT Involved:

• Eyelid skin (no external incision)
• Orbicularis oculi muscle
• Orbital septum (not opened)
• Orbital fat (not accessed)
• Levator muscle belly (not directly manipulated in pure MMCR)

Service Components

Included Services:

• Pre-operative measurements and phenylephrine test assessment
• Marking of resection amount on everted lid
• Anesthesia administration (local or local with sedation - general anesthesia separately billable if used)
• Eversion of upper eyelid with eversion clamps or sutures
• Application of specialized clamps (e.g., Putterman clamps) to mark tissue for resection
• Excision/resection of measured strip of conjunctiva, tarsus, and Müller’s muscle (typically 6-10mm depending on degree of ptosis)
• Suturing of cut conjunctival and tarsal edges (typically running 6-0 plain gut or Vicryl)
• Hemostasis
• Release of lid from eversion
• Assessment of lid height and contour
• Antibiotic/steroid ointment application
• Immediate post-operative care
• All routine post-operative care during 90-day global period:
  • Multiple post-operative visits
  • Suture removal if non-absorbable used (typically not needed)
  • Assessment of lid position and contour
  • Treatment of routine complications
  • Management of minor undercorrection or overcorrection
• Standard surgical supplies

Excludes:

• External levator resection or advancement (use 67903 or 67904 - different approaches)
• Frontalis suspension techniques (use 67901 or 67902 - for poor levator function)
• Superior rectus muscle transfer (use 67906 - complex severe ptosis)
• Correction of overcorrection as separate procedure (use 67909 if major revision needed)
• Upper lid blepharoplasty (use 15822 or 15823 - different diagnosis)
• Brow ptosis repair (use 67900 - different anatomic structure)
• Lower eyelid procedures
• Ectropion or entropion repair (67914-67924)
• Separate anesthesia provider charges (billable separately)
• Pre-operative comprehensive examination beyond standard evaluation

Unbundled/Separately Billable:

• Pre-operative comprehensive eye examination with modifier 57 if decision for surgery made
• Pre-operative phenylephrine testing (if billed separately, though often bundled)
• Unrelated E/M services during global period (modifier 24)
• Unrelated procedures during global period (modifier 79)
• Anesthesia services by separate anesthesia provider
• Concurrent procedures on fellow eye if separate medical necessity

RVU Information

Work RVU (wRVU): 5.30
Facility Total RVU: Approximately 8.18
Non-Facility Total RVU: Approximately 11.15
Global Days: 090 (90-day global surgical period)
Medicare Status: Active/Payable when medical necessity documented
2026 Medicare National Average:

• Facility: Approximately $265-285
• Non-Facility: Approximately $361-390
  (Varies by geographic locality and MAC)

RVU Comparison to Other Ptosis Procedures:

• 67908 (MMCR/Fasanella-Servat): 5.30 wRVU - Lowest among ptosis repairs
• 67903 (levator internal): 9.08 wRVU
• 67904 (levator external): 8.84 wRVU
• 67901 (frontalis suture): 9.79 wRVU
• 67902 (frontalis fascia): 12.64 wRVU

Lower RVU reflects less invasive technique, faster procedure time, and internal-only approach.

HCC Status

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

Assistant Surgeon Status

Assistant Payable: No (typically)

Medicare Assistant Surgeon Policy:

• CPT 67908 is generally designated as “Assistant surgeon may not be paid” (Indicator 1)
• This is a relatively straightforward, brief procedure typically not requiring assistant
• Most payers do not allow assistant surgeon payment for this code
• Assistant payment rarely approved even with documentation

Exceptions (Rare):
May be considered in extraordinary circumstances:

• Bilateral procedures in particularly difficult patient (extremely rare)
• Complex revision with extensive scarring (very unusual for this procedure)
• Patient factors making procedure unusually difficult (severe anxiety, movement disorder, etc.)

If Assistant Used (Unlikely to be Paid):

• Modifier 80 (physician assistant) or AS (PA/NP/CNS)
• Must document extraordinary circumstances requiring assistant
• Pre-authorization recommended (though likely to be denied)
• Most payers will deny regardless of documentation

Practical Reality:

• This procedure is typically performed solo by surgeon
• No assistant typically needed due to:
  • Short procedure time (15-30 minutes typical)
  • Internal approach with good visualization
  • No need for complex retraction
  • Surgeon can manage all aspects independently
• Using assistant generally not cost-effective as payment unlikely

Common Modifiers

Modifier	Description	Usage Frequency	Reimbursement Impact	Notes
-50	Bilateral procedure	High	150% of unilateral fee	Common for bilateral mild ptosis
-E1	Upper left eyelid	Moderate	100% first, 50% second	Alternative to modifier 50
-E3	Upper right eyelid	Moderate	100% first, 50% second	Alternative to modifier 50
-22	Increased procedural services	Rare	20-50% increase if justified	Rarely needed for this procedure
-51	Multiple procedures	Low	50% reduction secondary	When combined with other procedures
-52	Reduced services	Rare	Payment reduction	If procedure partially completed
-53	Discontinued procedure	Rare	Varies	If procedure stopped mid-surgery
-54	Surgical care only	Low	~70% of global	Transfer of care
-55	Postoperative management only	Low	~10% of global	Transfer of care
-56	Preoperative management only	Low	~20% of global	Transfer of care
-57	Decision for surgery	Common	Allows E/M day before/of surgery	Pre-op visit with decision
-58	Staged procedure	Low	100% for planned staged	If bilateral staged
-59	Distinct procedural service	Low	Bypasses NCCI edits	Rarely needed
-76	Repeat procedure by same physician	Low	Reduced during global	Adjustment needed
-78	Return to OR for complication	Low	~70% payment	Revision during global
-79	Unrelated procedure during global	Low	100% if unrelated	New global starts
-LT	Left side	Alternative	Alternative to E1	Some payers prefer
-RT	Right side	Alternative	Alternative to E3	Some payers prefer

Critical Modifier Notes:

• Bilateral (modifier 50): Very common with 67908 as mild bilateral ptosis is frequent indication
• E1/E3 vs 50: Either method acceptable; 50 preferred for efficiency
• Modifier 22: Rarely justified for this procedure as it’s relatively straightforward
• Modifier 52: Use if patient cannot tolerate completion or if procedure aborted

Common Associated CPT Codes

CPT Code	Description	Relationship to 67908	Billing Considerations
67903	Levator resection, internal approach	Alternative procedure	For moderate-severe ptosis; higher complexity
67904	Levator resection, external approach	Alternative procedure	External approach for moderate ptosis
67901	Frontalis suspension with suture	Alternative procedure	For poor levator function; not for 67908 candidates
67902	Frontalis suspension with fascia	Alternative procedure	Severe ptosis with poor levator
67906	Superior rectus technique	Alternative procedure	Complex severe ptosis
67909	Reduction of overcorrection	Follow-up procedure	If overcorrection occurs (different encounter)
15822	Upper lid blepharoplasty, skin only	May be combined	Separate diagnosis; document necessity
15823	Upper lid blepharoplasty with fat	May be combined	NCCI bundles; need modifier 59 with documentation
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	Exam under anesthesia	Pediatric cases	If needed for pediatric assessment
92060	Sensorimotor examination	Pre/post-operative	Assess motility
92081-92083	Visual field testing	Pre-operative	If claiming functional impairment
00103	Anesthesia for eyelid procedures	Related anesthesia	Billed by anesthesiologist/CRNA only
68200	Subconjunctival injection	May be combined	Steroid injection if needed

Common Combinations:

Bilateral MMCR:

• 67908-50 (most common billing)
• OR 67908-E3, 67908-E1 (separate lines)

MMCR + Blepharoplasty (Requires Documentation):

• 67908 (primary)
• 15822-51 or 15823-51 (secondary)
• Must document separate diagnoses: ptosis AND dermatochalasis
• NCCI may bundle; modifier -59 may be needed

Staged Bilateral:

• First eye: 67908-RT
• Second eye: 67908-58-LT (planned staged)

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: Internal Approach - Conjunctivo-Tarso-Müller Resection
Code: 67908

**Ptosis Repair Code Family with Code Selection:**
Blepharoptosis Repair Procedures (67901-67909)
├── Severe Ptosis / Poor Levator Function (<4-5mm)
│   ├── 67901 - Frontalis suspension with suture/synthetic
│   └── 67902 - Frontalis suspension with autologous fascia
│
├── Moderate Ptosis / Fair-Good Levator Function (5-10mm)
│   ├── 67903 - Levator resection, internal approach
│   └── 67904 - Levator resection, external approach
│
├── Mild-Moderate Ptosis / Good Levator Function (>10mm)
│   └── 67908 - MMCR/Fasanella-Servat ◄ Current Code
│
├── Severe Complex Ptosis
│   └── 67906 - Superior rectus technique with fascia
│
└── Revision/Correction
    └── 67909 - Reduction of overcorrection of ptosis

**Detailed Code Selection Algorithm:**
Patient with Upper Eyelid Ptosis?
│
├── Measure Levator Function (Excursion from Downgaze to Upgaze)
│   │
│   ├── Levator Function < 4-5mm (Poor/Absent)
│   │   └── Use Frontalis Suspension
│   │       ├── 67901 (suture/synthetic material)
│   │       └── 67902 (autologous fascia lata)
│   │
│   ├── Levator Function 5-10mm (Fair to Moderate)
│   │   └── Use Levator Resection/Advancement
│   │       ├── 67903 (internal approach preferred)
│   │       └── 67904 (external approach)
│   │
│   └── Levator Function > 10mm (Good)
│       │
│       └── Assess Degree of Ptosis
│           │
│           ├── Mild Ptosis (1-2mm) with Positive Phenylephrine Test
│           │   └── 67908 ◄ Current Code (MMCR/Fasanella-Servat)
│           │
│           └── Moderate Ptosis (2-3mm) with Good Levator
│               ├── 67908 (may be used for upper range)
│               └── 67903 or 67904 (if more correction needed)
│
└── Special Circumstances
    ├── Extremely Severe Ptosis, Failed Prior Surgeries
    │   └── 67906 (Superior rectus technique)
    │
    └── Post-operative Overcorrection
        └── 67909 (Reduction of overcorrection)

Key Distinguishing Features of 67908:

Ideal Candidates:

• Mild ptosis: 1-3mm
• Excellent levator function: >10mm (usually 12-15mm)
• Positive phenylephrine test (2.5% or 10% pheny elevates lid, indicating Müller’s function)
• Good tear production (procedure done from conjunctival side)
• No significant dermatochalasis requiring skin excision
• Patient prefers no external scar

Advantages of 67908:

• No external incision (no visible scar)
• Faster recovery
• Less post-operative swelling
• Minimal tissue disruption
• Outpatient procedure under local anesthesia
• Good predictability with proper patient selection

Limitations:

• Only suitable for mild-moderate ptosis
• Requires good levator function
• Cannot address dermatochalasis
• Limited correction amount (typically 1.5-3mm lift)
• Higher risk of undercorrection if levator function overestimated

Coding Examples

Example 1: Bilateral Mild Ptosis - Phenylephrine Test Positive

Patient Presentation: 45-year-old female with bilateral upper lid ptosis noticed over past 2 years. Complains of tired appearance and mild visual field obstruction superiorly.

Pre-operative Assessment:

• MRD1: 2.5mm OD, 2mm OS (mild ptosis; normal 4-5mm)
• Levator function: 14mm OU (excellent; normal >12mm)
• Phenylephrine 2.5% test: Lid elevation 2mm OU (positive test indicating good Müller’s muscle function)
• Bell’s phenomenon: Good bilaterally
• No significant dermatochalasis
• Superior visual field: Mild superior defects bilaterally, improve with lid taping
• Diagnosis: Bilateral mild acquired aponeurotic ptosis with excellent levator function

Surgical Planning:

• Müller’s muscle-conjunctival resection (MMCR) appropriate due to:
  • Excellent levator function (>10mm)
  • Positive phenylephrine test
  • Mild ptosis (2-2.5mm)
  • Patient prefers internal approach (no external scar)
• Plan 8mm resection bilaterally

Surgery Performed: Bilateral MMCR (67908)

• Local anesthesia: 2% lidocaine with epinephrine injected subconjunctivally
• Right upper lid:
  • Lid everted with Desmarres retractor
  • Superior tarsus and conjunctiva marked for 8mm resection
  • Putterman clamp applied to mark tissue
  • Measured strip of conjunctiva, superior tarsus, and Müller’s muscle excised
  • Cut edges sutured with running 6-0 plain gut suture
  • Hemostasis achieved with bipolar cautery
  • Lid released, height assessed: MRD1 now 4mm (good correction)
• Left upper lid: Same procedure, 8mm resection
  • Post-excision MRD1: 4mm (symmetric with right)
• Antibiotic/steroid ointment applied
• Ice compresses
• Patient tolerated well, discharged home

Post-operative Plan:

• Antibiotic-steroid ointment QID for 1 week
• Artificial tears as needed
• Follow-up: Day 1, Week 1, Month 1, Month 3
• Monitor for undercorrection or overcorrection
• Educate on lagophthalmos possibility (minimal expected)

Coding:

• 67908-50 - Repair of blepharoptosis, conjunctivo-tarso-Müller’s muscle resection, bilateral

Diagnoses:

• H02.411 - Mechanical ptosis of right upper eyelid
• H02.412 - Mechanical ptosis of left upper eyelid
• H53.461 - Visual field defect, upper right
• H53.462 - Visual field defect, upper left

Supporting Documentation:

• Pre-operative measurements (MRD1, levator function)
• Phenylephrine test results (positive)
• Pre-operative photographs showing mild ptosis
• Visual field testing if claiming functional impairment
• Operative report detailing technique and measurements

Medical Necessity: Functional impairment with documented visual field defects; excellent surgical candidate for MMCR.

Reimbursement: 150% of unilateral allowable with modifier 50.

Example 2: Unilateral Mild Ptosis - Asymmetric Eyes

Patient: 38-year-old male with right upper lid drooping since childhood, worse recently. Left eye normal. Bothered by asymmetry.

Pre-operative Findings:

• Right ptosis: MRD1 2mm (mild)
• Left normal: MRD1 4.5mm
• Levator function: 13mm OD (excellent), 14mm OS
• Phenylephrine test: Right lid elevates 2.5mm (positive)
• No dermatochalasis
• Diagnosis: Congenital right ptosis, mild, with excellent levator function

Surgery: Right MMCR (67908)

• 8.5mm resection of conjunctiva/tarsus/Müller’s muscle
• Final MRD1: 4.5mm OD (matches left)

Coding:

• 67908-E3 (or 67908-RT) - MMCR, right upper lid only

Diagnoses:

• Q10.0 - Congenital ptosis (if documenting congenital origin)
• H02.411 - Mechanical ptosis of right upper eyelid

Notes:

• Unilateral procedure: 100% of allowable (no bilateral reduction)
• Do NOT use modifier 50 (not bilateral)
• Do NOT use modifier 52 (full procedure performed on one side)

Example 3: Bilateral MMCR with Concurrent Minimal Dermatochalasis

Patient: 58-year-old female with bilateral mild ptosis AND minimal upper lid skin redundancy. Both conditions contribute to visual field obstruction.

Pre-operative Assessment:

• Ptosis: MRD1 2mm OU
• Levator function: 12mm OU (good)
• Minimal dermatochalasis (skin barely touching lashes at rest)
• Phenylephrine test: Positive bilaterally
• Visual fields: Superior defects from BOTH ptosis and skin
• Assessment: Both ptosis AND dermatochalasis present

Surgical Planning Discussion with Patient:

• MMCR alone may not fully address visual field loss due to skin component
• Options:
  1. MMCR alone (addresses ptosis only)
  2. Blepharoplasty alone (addresses skin only)
  3. Combined procedure (addresses both)
• Patient elects combined approach

Surgery Performed:

1. Bilateral MMCR (67908): Internal approach for ptosis correction
2. Bilateral minimal skin excision blepharoplasty (15822): External skin removal

Operative Report Documentation:

• Clear documentation of TWO separate conditions:
  • Blepharoptosis from levator/Müller weakness (needs 67908)
  • Dermatochalasis causing additional visual obstruction (needs 15822)
• Separate measurements supporting each diagnosis
• Both procedures necessary to fully address visual field obstruction
• MMCR performed first from internal approach
• Blepharoplasty performed second from external approach through lid crease

Coding:

• 67908-50 - Bilateral MMCR (PRIMARY code)
• 15822-51-50 - Bilateral blepharoplasty skin only (SECONDARY with modifier 51)

Alternative Coding Method:

• 67908-E3 - MMCR right
• 67908-E1 - MMCR left
• 15822-51-E3 - Bleph right (modifier 51 for multiple procedure)
• 15822-51-E1 - Bleph left (modifier 51)

Diagnoses:

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

Critical Documentation Requirements:

• Must document that BOTH conditions exist independently
• Cannot correct one without addressing the other
• Separate measurements for ptosis and dermatochalasis
• Visual field testing supports both pathologies
• Medical necessity clearly stated for both procedures

NCCI Considerations:

• 15822 may bundle into 67908 depending on NCCI version
• Modifier 51 indicates multiple procedures
• May need modifier 59 to bypass edit with strong documentation
• Prior authorization strongly recommended
• Some payers may deny 15822 even with documentation

Payer Response Variability:

• Some payers approve combination with strong documentation
• Others consider blepharoplasty included in ptosis repair
• Documentation must be exceptionally clear
• Be prepared for potential denial and appeal

Example 4: Staged Bilateral MMCR

Patient: 62-year-old on anticoagulation (warfarin) with bilateral mild ptosis. Due to bleeding risk, surgeon recommends staging.

Pre-operative Assessment:

• Bilateral mild ptosis: MRD1 2.5mm OU
• Levator function: 13mm OU
• Phenylephrine test: Positive OU
• Medical history: Atrial fibrillation on warfarin (INR therapeutic)
• Cardiology consultation: Cannot safely stop anticoagulation
• Decision: Stage procedure to minimize bleeding risk

Surgery #1 (Initial Date):

• Right MMCR performed
• Increased oozing noted due to anticoagulation, managed with cautery
• Patient tolerates well
• Plan: Left side in 4 weeks after right heals

Coding Surgery #1:

• 67908-RT (or 67908-E3) - MMCR, right upper lid

Surgery #2 (4 Weeks Later):

• Left MMCR performed
• Right side healing well
• Similar bleeding managed appropriately

Coding Surgery #2:

• 67908-58-LT (or 67908-58-E1) - MMCR left, staged procedure

Modifier 58 Explanation:

• Indicates PLANNED staged procedure
• Documents that staging was prospectively intended, not due to complication
• Allows full reimbursement for second eye (not reduced to 50% bilateral rate)
• Second procedure starts new 90-day global period

Documentation Requirements:

• First operative report must state: “Plan to stage left eye in 3-4 weeks due to anticoagulation status and bleeding risk”
• Medical necessity for staging documented (bleeding risk on warfarin)
• Both procedures medically necessary
• Not staged for convenience or patient preference alone

Diagnoses:

• H02.411, H02.412 - Bilateral mechanical ptosis
• I48.91 - Atrial fibrillation, unspecified
• Z79.01 - Long-term use of anticoagulants

Without Modifier 58:
If procedures were NOT prospectively planned to be staged:

• Second surgery would be billed as simple contralateral procedure
• Subject to bilateral payment rules (50% reduction on second eye)
• Using modifier 58 with proper documentation avoids this reduction

Example 5: Unsuccessful MMCR Requiring Revision

Patient: 52-year-old female who underwent bilateral MMCR 6 months ago. Persistent undercorrection bilaterally (MRD1 only improved from 2mm to 3mm bilaterally, target was 4-5mm).

Assessment:

• Undercorrection from initial MMCR
• MRD1: 3mm OU (improved from 2mm but still 1-2mm low)
• Levator function: Still 12mm OU (good)
• Options discussed:
  1. Repeat MMCR (may have limited tissue remaining)
  2. Convert to external levator advancement (67904)
  3. Conservative management
• Patient elects external levator approach for more predictable correction

Surgery: Bilateral external levator advancement (67904)

• Cannot simply repeat 67908 due to already resected tissues
• External approach chosen for better control

Coding:

• 67904-50 - Levator resection external approach, bilateral (NOT 67908)

Note: This is a NEW procedure (67904), not a repeat of 67908

• Outside original 90-day global period
• Different technique (external vs internal)
• No modifier 76 (not repeat of same procedure)
• No modifier 78 (not return to OR for complication during global)

Diagnoses:

• H02.412 - Mechanical ptosis left upper eyelid, recurrent
• H02.411 - Mechanical ptosis right upper eyelid, recurrent
• May include: History of prior ptosis surgery (code as status post-surgical if available)

Learning Point: MMCR has higher undercorrection rate than external levator surgery. Patient selection critical. Consider external approach if larger correction needed or if levator function borderline.

Example 6: Pediatric Mild Congenital Ptosis

Patient: 8-year-old child with congenital bilateral mild ptosis. No amblyopia. Levator function good.

Pre-operative Findings:

• Bilateral mild ptosis: MRD1 2.5mm OU
• Levator function: 11mm OU (good for child)
• No amblyopia (vision 20/20 OU with glasses)
• Phenylephrine test: Positive bilaterally (2mm elevation)
• Parents concerned about appearance and child starting to notice asymmetry
• Assessment: Congenital ptosis, mild, suitable for MMCR

Surgical Considerations:

• MMCR can be used in pediatric patients with good levator function
• Advantages: Internal approach, no external scar, faster recovery
• Disadvantage: Requires cooperative child for local anesthesia OR general anesthesia

Surgery: Bilateral MMCR under general anesthesia

• General anesthesia by anesthesiologist (billed separately)
• Bilateral MMCR performed with 7.5mm resection each side
• Intraoperative lid adjustment under anesthesia guidance
• Good final position achieved

Coding:

• 67908-50 - Bilateral MMCR
• Anesthesiologist separately bills: 00103 (anesthesia for eyelid procedures)

Diagnoses:

• Q10.0 - Congenital ptosis (primary diagnosis for pediatric congenital ptosis)
• H02.421 - Myogenic ptosis, right upper eyelid (can also use)
• H02.422 - Myogenic ptosis, left upper eyelid (can also use)

Special Pediatric Considerations:

• Medical necessity: Congenital ptosis even if mild can be covered for functional/developmental reasons
• Prevent amblyopia (though already ruled out in this case)
• Psychosocial impact (child’s self-esteem)
• Document developmental appropriateness of intervention
• May require exam under anesthesia (92018) if cannot cooperate for measurements

Documentation Requirements

Pre-operative Documentation Required:

Clinical History:

• Chief complaint: Drooping eyelid, tired appearance, visual obstruction
• Duration: Congenital vs acquired, progression over time
• Variability: Worse when tired (suggests myasthenia), constant (suggests mechanical)
• Previous treatments or surgeries
• Impact on vision and daily activities
• Symptoms: Difficulty reading, driving, cosmetic concerns
• Medical history: Myasthenia gravis, neurologic conditions, trauma
• Medications: Especially those affecting Müller’s muscle (alpha agonists)

Physical Examination - Critical Measurements:

Essential Measurements for Code Selection:

• MRD1 (Margin-Reflex Distance): 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
  • 67908 typically used for MRD1 of 2-3.5mm (mild ptosis)
• Levator Function: Excursion of lid from complete downgaze to maximum upgaze with frontalis muscle immobilized
  • Excellent: >12mm
  • Good: 10-12mm
  • Fair: 5-9mm
  • Poor: <5mm
  • 67908 requires levator function >10mm (preferably >12mm)

Phenylephrine Test (Critical for 67908 Selection):

• Instill 2.5% or 10% phenylephrine into superior fornix
• Wait 5-10 minutes
• Measure lid elevation
• Positive test: Lid elevation ≥1mm (preferably ≥1.5-2mm)
• Positive phenylephrine test predicts good MMCR result
• Must document phenylephrine test result in chart

Other Measurements:

• Lid crease height (high crease suggests aponeurotic ptosis)
• Palpebral fissure height
• Bell’s phenomenon (assess lagophthalmos risk)
• Pupil size and position
• Corneal sensation
• Tear production (Schirmer’s test if indicated)
• Fellow eye for comparison
• Assessment for dermatochalasis, brow ptosis (concurrent conditions)

Objective Testing:

• Visual acuity
• Pupil examination
• Motility assessment
• Visual field testing if claiming functional impairment
• Pre-operative photographs (REQUIRED):
  • Front view primary gaze
  • Upgaze view
  • Downgaze view
  • Lateral views
  • Photos with phenylephrine effect if possible

Indication for MMCR (67908) vs Other Ptosis Repairs:

Document Why MMCR is Appropriate:

• Mild ptosis (1-3mm, MRD1 of 2-3.5mm)
• Excellent levator function (>10mm, preferably >12mm)
• Positive phenylephrine test (lid elevates ≥1mm with pheny)
• No significant dermatochalasis requiring skin excision
• Patient desires internal approach or external scar avoidance
• Good candidate for local anesthesia with or without sedation

Contraindications for MMCR (Use Different Code):

• Severe ptosis (>3mm) - use levator advancement (67903/67904)
• Poor levator function (<10mm) - use frontalis suspension (67901/67902)
• Significant dermatochalasis - use blepharoplasty (15822/15823) with or without ptosis repair
• Negative phenylephrine test - consider levator advancement instead
• Previous failed MMCR - use external approach (67904)

Informed Consent Documentation:
Discuss and document:

• Expected degree of correction (typically 1.5-3mm lift)
• Possible asymmetry between eyes
• Risk of undercorrection (more common with MMCR than external approaches)
• Risk of overcorrection (less common but possible)
• Minimal lagophthalmos (usually less than with other ptosis repairs)
• No external scar but internal sutures
• Need for possible revision if undercorrection
• Alternative techniques discussed (levator advancement, frontalis suspension)

Operative Report Must Include:

Standard Elements:

• Patient identification and date of service
• Pre-operative diagnosis: Blepharoptosis, mild, with good levator function (specify etiology if known)
• Post-operative diagnosis: Same
• Procedure name: Repair of blepharoptosis, conjunctivo-tarso-Müller’s muscle resection (Fasanella-Servat type or MMCR)
• Surgeon, assistants (if any), anesthesia type
• Indication for surgery

Detailed Procedure Description Must Document:

Critical Elements for Code 67908:

• Patient positioning and preparation
• Anesthesia type: Local (infiltration or topical) with or without sedation
• Eyelid eversion technique:
  • Instillation of topical anesthetic
  • Placement of eversion sutures or use of Desmarres retractor
  • Complete eversion of upper eyelid exposing tarsal conjunctiva
• Marking of resection:
  • Measurement of amount to resect (typically 6-10mm depending on phenylephrine response and desired correction)
  • Marking on conjunctival surface at superior tarsal border
• Clamping technique:
  • Placement of specialized clamp (e.g., Putterman clamp) to mark tissue and provide hemostasis
  • Documentation that clamp includes conjunctiva, tarsus, and Müller’s muscle
  • Amount of tissue in clamp (e.g., “8mm of tissue clamped”)
• Excision:
  • Excision of clamped tissue strip
  • Documentation of structures removed: Conjunctiva, superior tarsus, Müller’s muscle
  • May include small amount of levator aponeurosis (traditional Fasanella-Servat) or spare levator (modern MMCR) - specify
• Suturing:
  • Running or interrupted suture of cut edges
  • Suture type: typically 6-0 plain gut, 6-0 Vicryl, or 6-0 silk
  • Suture buried on conjunctival side (not exposed to cornea)
• Hemostasis:
  • Method of achieving hemostasis (usually clamping, then bipolar cautery if needed)
  • Documentation of adequate hemostasis
• Release and assessment:
  • Release of lid from eversion
  • Assessment of lid height immediately post-procedure
  • Target MRD1 achieved (document measurement)
  • Lid contour assessed (smooth vs peaked)
• Closure (if any external component - rare for pure MMCR):
  • Usually NO external closure (internal procedure only)
• Dressing: Antibiotic-steroid ointment, ice packs
• Patient condition and disposition

Must Clearly Document:

• Internal approach (posterior eyelid surface)
• Resection of conjunctiva AND tarsus AND Müller’s muscle
• No external skin incision
• Amount of tissue resected (mm)
• Final lid position

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

• Lid position (MRD1 measurements)
• Lid contour (smooth, peaked, or irregular)
• Lagophthalmos assessment (usually minimal with MMCR)
• Corneal status (exposure risk lower than other ptosis repairs)
• Symmetry between eyes if bilateral
• Any complications: Undercorrection, overcorrection, entropion, conjunctival prolapse
• Treatment of complications if any
• Final outcome assessment

Billing Guidelines and Best Practices

Global Surgical Package (90-Day Global Period):

Included in 67908 Payment:

• Pre-operative visit day of or day before surgery (unless decision visit - modifier 57)
• Intraoperative services
• All post-operative visits for 90 days:
  • Day 1 visit
  • Week 1 visit
  • Subsequent visits as needed for routine care
  • Suture removal (if non-absorbable sutures used - uncommon)
  • Assessment of lid position and contour
  • Treatment of routine complications (minor suture irritation, mild undercorrection counseling)
  • Lubrication management
• Standard surgical supplies

NOT Included (Separately Billable):

• E/M visit where decision for surgery made (modifier 57 if day before or day of major surgery)
• Pre-operative phenylephrine testing (if billed separately - often considered part of exam)
• Pre-operative visual field testing (92081-92083)
• Unrelated E/M services during global period (modifier 24)
• Unrelated procedures during global period (modifier 79)
• Anesthesia services by separate provider (anesthesiologist/CRNA)
• Major revision surgery for undercorrection (may be modifier 78 if during global, or new procedure if after global)

Bilateral Procedure Billing:

Method 1 (Preferred): Modifier 50

• Code: 67908-50
• Payment: 150% of unilateral allowable
• Single line item
• Most efficient

Method 2: Anatomic Modifiers

• Line 1: 67908-E3 (right) = 100%
• Line 2: 67908-E1 (left) = 50% (automatic reduction)
• Total: 150%
• Two line items

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

Staged Bilateral Procedures:

• First eye: 67908-RT = 100%
• Second eye (later date): 67908-58-LT = 100% with modifier 58
• Modifier 58 indicates prospectively planned staged procedure
• Allows full reimbursement for second eye
• Must document medical necessity for staging in first operative report

Medicare Coverage Criteria:

Covered When:

• Functional visual impairment from ptosis
• Symptoms affecting daily activities or quality of life
• Documented ptosis severity (MRD1, levator function, phenylephrine test)
• Good levator function supporting MMCR technique
• Medical necessity documented
• Conservative management not applicable or failed

Typical Coverage Scenarios:

• Acquired aponeurotic ptosis, mild, with good levator function
• Congenital ptosis, mild, with adequate levator
• Post-traumatic ptosis with preserved levator function
• Phenylephrine-responsive ptosis

NOT Typically Covered:

• Purely cosmetic desire for wider palpebral fissure without functional impairment
• Severe ptosis better treated with different technique
• Poor levator function (wrong procedure choice)
• Negative phenylephrine test without documented alternative rationale

Prior Authorization:

• Medicare: Usually not required but check MAC
• Medicare Advantage: Often requires prior authorization
• Commercial payers: Variable; many require auth
• Submit with authorization:
  • Clinical notes with measurements (MRD1, levator function, phenylephrine result)
  • Pre-operative photographs
  • Visual field testing if functional obstruction claimed
  • Justification for MMCR technique selection

Modifier 22 for Increased Complexity:

Rarely Applicable to 67908:

• MMCR is generally straightforward, brief procedure
• Modifier 22 rarely justified unless:
  • Extensive scarring from prior surgery (revision MMCR - uncommon)
  • Severe conjunctival scarring from disease (Stevens-Johnson, chemical burn)
  • Unusually difficult anatomy
  • Significantly prolonged operative time with documented reason

If Using Modifier 22:

• Operative report must document significantly increased difficulty
• Compare to typical 67908 (usually 15-30 minutes)
• Explain specific challenges encountered
• Cover letter requesting additional payment
• Success rate variable; requires compelling documentation

NCCI Edits - Bundling Rules:

Codes That May Bundle INTO 67908:

• Blepharoplasty codes (15822, 15823) - depending on edit version
• Check current NCCI edits before billing combinations
• If both ptosis AND dermatochalasis present:
  • Must document TWO separate conditions
  • Medical necessity for BOTH procedures
  • Modifier 59 or XE/XS/XP/XU may be needed
  • Prior authorization recommended
  • Some payers deny combination regardless

Codes That Can Be Billed With 67908:

• Examination codes with modifier 57 (decision visit)
• Visual field testing (pre-operative)
• Brow ptosis repair (67900) if concurrent brow ptosis
• Fellow eye procedures if separate medical necessity

Multiple Procedure Payment Reduction:
When 67908 billed with other procedures:

• Higher RVU code typically paid at 100%
• 67908 often secondary code (lower RVU than many procedures)
• Secondary procedures reduced 50% with modifier 51
• Check payer-specific multiple procedure rules

Unilateral vs Bilateral Payment:

• Unilateral: 100% of allowable
• Bilateral with modifier 50: 150% of allowable (not 200%)
• Each eye separately with E1/E3: 100% + 50% = 150%
• Staged bilateral with modifier 58: 100% each encounter if prospectively planned

Cosmetic vs Functional Compliance:

Functional (Covered):

• Visual field obstruction from ptosis
• Symptoms affecting daily function (reading, driving, headaches from compensatory brow elevation)
• MRD1 below normal (at or below pupil margin ideal)
• Documented measurements supporting severity
• Good surgical candidate (positive phenylephrine test)

Cosmetic (Not Covered):

• Aesthetic preference for more “open” eyes
• Minimal ptosis without functional impact
• No symptoms
• Normal or near-normal visual function
• Purely appearance-based motivation

Critical Compliance Issues:

• Never upcode cosmetic as functional
• Measurements must support ptosis severity
• Phenylephrine test should be documented (supports technique choice)
• Photographs essential
• Use appropriate diagnosis codes
• Informed consent documents risks and alternatives

Audit Risk Factors:

• High volume of ptosis surgeries without proper documentation
• Always billing bilateral
• Frequently combining with blepharoplasty
• Missing phenylephrine test documentation
• Inadequate levator function documentation
• Template notes lacking individualization
• Billing 67908 when measurements suggest need for different technique

Best Practices for Compliance:

• Document MRD1, levator function, and phenylephrine test EVERY case
• Take standardized photographs (pre-op mandatory)
• Individualize documentation (avoid templates)
• Document rationale for MMCR selection over other techniques
• When combining procedures, document separate medical necessity
• Appropriate follow-up during global period
• Code accurately based on actual technique performed
• If procedure aborted or modified, use appropriate modifier

Common Billing Errors to Avoid:

Wrong Code Selection:

• Using 67908 when levator function poor (<10mm) - should use 67901/67902
• Using 67908 for moderate-severe ptosis - should use 67903/67904
• Using 67908 when external levator surgery performed - should use 67904

Modifier Errors:

• Using modifier 50 AND E1/E3 together (redundant)
• Not using modifier 58 when staging bilateral procedure (loses reimbursement)
• Using modifier 22 without adequate documentation

Documentation Errors:

• Missing phenylephrine test results
• Missing levator function measurement
• Missing pre-operative photographs
• Operative report doesn’t specify internal approach
• Operative report doesn’t document conjunctiva/tarsus/Müller’s resection

Bundling Errors:

• Billing blepharoplasty with ptosis repair without documentation of both conditions
• Not using modifier when NCCI edit requires it
• Billing separately for services included in global package

Clinical Indications and Diagnosis Codes

Primary Diagnoses for MMCR (67908):

Acquired Ptosis:

Mechanical/Aponeurotic Ptosis (Most Common for MMCR):

• H02.411 - Mechanical ptosis of right upper eyelid
• H02.412 - Mechanical ptosis of left upper eyelid
• H02.413 - Mechanical ptosis of bilateral upper eyelids

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

Unspecified Ptosis:

• H02.401 - Unspecified ptosis of right eyelid
• H02.402 - Unspecified ptosis of left eyelid
• H02.403 - Unspecified ptosis of bilateral eyelids

Congenital Ptosis (Mild Cases with Good Levator):

• Q10.0 - Congenital ptosis

Supporting/Secondary Diagnoses:

Visual Field Impairment:

• H53.461 - Sector or arcuate visual field defect, upper right
• H53.462 - Sector or arcuate visual field defect, upper left
• H53.463 - Bilateral sector or arcuate visual field defects, upper
• H53.40 - Unspecified visual field defects

Concurrent Conditions (If Addressing):

• H02.31-H02.33 - Dermatochalasis (if concurrent minimal bleph performed - requires strong documentation)
• H53.031-H53.033 - Amblyopia suspect (pediatric cases)

Underlying Systemic Conditions (Supporting Documentation):

• Myasthenia gravis (G70.00) - though typically NOT ideal for MMCR; MG patients better with adjustable procedures
• Third nerve palsy (H49.00-H49.03) - if partial recovery with residual mild ptosis
• Post-traumatic states (document trauma history)

Diagnoses That Should NOT Be Primary for 67908:

Severe Ptosis Requiring Different Technique:

• When MRD1 <1mm or negative - needs more extensive procedure (67903/67904 or 67901/67902)

Poor Levator Function:

• When levator function <10mm - needs frontalis suspension (67901/67902)

Primary Dermatochalasis Without Ptosis:

• H02.31-H02.33 alone without concurrent H02.40x codes - needs blepharoplasty (15822/15823), not ptosis repair

Incorrect Diagnosis Coding Pitfalls:

• Using only visual field codes without ptosis diagnosis - insufficient
• Using dermatochalasis codes without ptosis codes when ptosis is primary problem
• Using severe ptosis measurements with 67908 - procedure/diagnosis mismatch
• Not specifying laterality (right, left, bilateral)

Diagnosis Documentation Tips:

• Always specify laterality
• Use most specific code available
• Primary diagnosis should be ptosis (H02.40x or Q10.0)
• Add visual field codes as supporting when applicable
• Document severity in clinical notes even if not captured in ICD-10
• For bilateral cases, may list both eyes separately or use bilateral code depending on documentation preference