Crystal's MCW Coder Hub🩺CPT 67935 — Repair of Eyelid Involving Lid Margin, Tarsus, and/or Palpebral Conjunctiva; Involving Over One-Fourth of Lid Margin, Full Thickness
Code Description
CPT 67935 describes a full-thickness repair of the eyelid involving the lid margin when the defect encompasses more than one-fourth (greater than 25%) of the total horizontal lid margin length. This is a major eyelid reconstruction code that captures complex, full-thickness eyelid repairs requiring reconstruction of all anatomic layers of the eyelid — the anterior lamella (skin and orbicularis oculi muscle), the posterior lamella (tarsus and palpebral conjunctiva), and the lid margin itself.
The full CPT descriptor reads: Repair of eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva; over one-fourth of lid margin, full thickness.
The designation “full thickness” is critical — it distinguishes this code from partial-thickness repairs and establishes that the defect traverses the entire eyelid from anterior skin surface through to the posterior conjunctival surface. Full-thickness eyelid defects involving more than 25% of the lid margin cannot be closed primarily with simple suture alone without distortion of the eyelid architecture, and typically require one or more reconstructive techniques to restore both lid margin integrity and functional eyelid mechanics.
The eyelid serves essential protective and optical functions — it distributes the tear film across the corneal surface with each blink, protects the globe from foreign bodies and desiccation, and modulates the amount of light reaching the retina. Large full-thickness defects that are inadequately repaired can result in corneal exposure, exposure keratopathy, secondary infection, and vision loss.
The threshold of one-fourth (25%) of the lid margin is anatomically significant. The average upper eyelid horizontal span is approximately 28-32 mm, and the lower eyelid is approximately 26-30 mm. A defect of greater than one-fourth therefore represents approximately 7-8 mm or more of horizontal lid margin involvement — a defect that, in most patients, cannot be closed by simple pentagonal wedge excision and direct closure without significant lid distortion, lagophthalmos, or ectropion.
Anatomic Context
Understanding the layered anatomy of the eyelid is essential for accurate coding of eyelid repair procedures:
Anterior Lamella
- Eyelid skin — among the thinnest skin in the human body (0.5-1.0 mm), highly mobile, with minimal subcutaneous fat
- Orbicularis oculi muscle — the circumferential striated muscle responsible for eyelid closure; divided into orbital, preseptal, and pretarsal portions
Posterior Lamella
- Tarsus (tarsal plate) — a dense fibrous connective tissue structure providing structural rigidity to the eyelid; upper tarsus is approximately 8-12 mm in vertical height, lower tarsus approximately 3-5 mm
- Palpebral conjunctiva — the mucous membrane lining the inner surface of the eyelid, continuous with the bulbar conjunctiva at the fornix; provides a smooth lubricated surface against the globe
Lid Margin
- The free edge of the eyelid where anterior and posterior lamellae meet
- Contains the gray line (the intermarginal sulcus, marking the mucocutaneous junction and plane between anterior and posterior lamellae)
- Houses the meibomian gland orifices (posterior to the gray line)
- Contains the eyelashes (cilia) and their follicles (anterior to the gray line)
- Contains the punctum lacrimale (medially) for tear drainage
Full-thickness repair requires restoration of all of these components to prevent trichiasis, entropion, ectropion, eyelash misdirection, punctal malposition, and corneal exposure.
Operative Overview
The specific reconstructive technique employed depends on the location of the defect (upper vs. lower lid), the extent of horizontal and vertical involvement, tissue availability, patient age and skin laxity, and the underlying etiology (trauma vs. post-tumor excision vs. congenital). Common techniques used for defects involving more than one-fourth of the lid margin include:
Techniques for Lower Eyelid Reconstruction (>25% defect)
Tenzel Semicircular Rotational Flap A semicircular myocutaneous flap rotated from the lateral canthal region to advance tissue medially. The lateral canthal tendon is released (lateral canthotomy and cantholysis) to allow flap advancement. Suitable for defects of 33-50% of the lower lid. The posterior lamella must be separately reconstructed with a free tarsoconjunctival graft or mucosal graft if insufficient tarsus remains.
Hughes Tarsoconjunctival Flap (Modified Hughes Procedure) For larger lower eyelid defects (50-100%), a bipedicled tarsoconjunctival flap is advanced from the upper eyelid to reconstruct the posterior lamella of the lower eyelid. The anterior lamella is then reconstructed with a full-thickness skin graft (from the contralateral upper eyelid, retroauricular skin, or supraclavicular skin) or a myocutaneous advancement flap. The flap is divided as a second-stage procedure approximately 4-8 weeks later. This is one of the most commonly performed lower eyelid reconstructive procedures for large defects.
Cutler-Beard Procedure (Bridge Flap) Used for large upper eyelid defects (>50%). A full-thickness segment of the lower eyelid below the lid margin is advanced under a bridge of intact lower lid margin into the upper eyelid defect. Requires a second-stage division approximately 6-8 weeks later. Results in a two-stage reconstruction with temporary closure of the visual axis.
Fricke Flap / Mustardé Cheek Rotation Flap Large regional flaps used when local tissue is insufficient, particularly for very large defects or after oncologic resection.
Free Tarsal Graft / Hard Palate Mucosal Graft Used to reconstruct the posterior lamella when ipsilateral or contralateral upper eyelid tarsus is insufficient or unavailable. Hard palate mucosal grafts provide an excellent substitute for conjunctiva/tarsus in posterior lamellar reconstruction.
Medial Canthal Reconstruction When the defect involves the medial lid margin, canalicular reconstruction with monocanalicular or bicanalicular silicone stent intubation may be required and is reported separately.
Includes
- Full-thickness eyelid repair with reconstruction of the lid margin involving more than 25% of the total horizontal lid margin
- Reconstruction of the anterior lamella (skin and orbicularis) using local tissue advancement, rotation flaps, or skin grafts that are part of the primary reconstructive effort
- Reconstruction of the posterior lamella (tarsus and palpebral conjunctiva) using local tarsoconjunctival tissue, advancement flaps (such as the Hughes flap), or grafts performed during the same operative session
- Lateral canthotomy and cantholysis performed as a component of the reconstructive approach (e.g., Tenzel flap)
- Suture repair of the gray line, posterior lid margin, and anterior lid margin
- Placement of silicone stents or temporary tarsorhaphies when integral to the primary repair
- Wound closure, including layered closure of skin and deeper structures
- Local anesthetic injection for operative field anesthesia
Excludes / Report Separately
- Repair of eyelid involving one-fourth or less of the lid margin — reported with CPT 67930 (not this code; the smaller defect code)
- Simple laceration repair of eyelid skin only (without lid margin involvement) — reported with wound repair codes (CPT 12011-12018, 12031-12037, or 13150-13153 depending on complexity and length) rather than the eyelid-specific codes
- Canalicular laceration repair — CPT 68700 (plastic repair of canaliculi); if the medial lid defect involves the canalicular system and formal canalicular repair with intubation is performed, report 68700 separately with appropriate documentation
- Enucleation or evisceration — reported separately if performed at the same session
- Excision of eyelid lesion (e.g., skin tag, benign neoplasm) performed at a separately identifiable site — report separately (CPT 67800, 67805, 67808, or excision codes as appropriate)
- Mohs micrographic surgery — performed by dermatologist/Mohs surgeon prior to reconstruction; the Mohs excision (CPT 17311-17315) is reported by the Mohs surgeon; the oculoplastic surgeon’s reconstructive work is reported separately by the reconstructing surgeon using the appropriate eyelid repair code (67930 or 67935 depending on extent)
- Second-stage flap division — when a two-stage procedure is performed (e.g., Hughes flap division, Cutler-Beard flap division at a second operative session), the second-stage procedure is reported separately. The appropriate CPT code for the second stage depends on the procedure performed — typically a flap division and inset code or a separately defined reconstruction code
- Skin graft harvested from a distant donor site — if a full-thickness skin graft (FTSG) is harvested from a non-adjacent donor site (e.g., retroauricular, supraclavicular), the skin graft may be separately reportable with CPT 15260 (full-thickness skin graft, face) or 15261, depending on size and donor site — review NCCI edits and payer policy carefully, as bundling rules vary
- Blepharoplasty — functional or cosmetic blepharoplasty (CPT 15820-15823 or 67900-67904) performed at a separate and distinct site on the eyelid is not bundled into 67935 and may be separately reported
- Ptosis repair performed at the same session on a separate eyelid — may be separately reportable with appropriate modifiers
- Orbital floor or wall repair — separately reportable (CPT 21385-21395) if performed at the same session for orbital blowout fracture
- Levator repair — CPT 67901-67908 depending on technique; separately reportable if performed at a distinct site
- Conjunctivoplasty / fornix reconstruction — CPT 68320 or 68325; separately reportable if performed at a site distinct from the eyelid margin repair
Code Tree — Eyelid Repair and Reconstruction CPT Codes
| CPT Code | Description |
|---|---|
| 67930 | Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; not involving one-fourth of lid margin |
| 67935 | Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva; over one-fourth of lid margin — this code |
| 67950 | Canthoplasty (reconstruction of canthus) |
| 67961 | Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; not more than one-fourth of lid margin |
| 67966 | Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; over one-fourth of lid margin |
| 67971 | Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, one stage or first stage |
| 67973 | Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, one stage or first stage |
| 67974 | Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, one stage or first stage |
| 67975 | Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia) |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) |
| 67908 | Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat type) |
| 67961 | Excision and repair of eyelid not more than one-fourth of lid margin, full thickness |
| 67966 | Excision and repair of eyelid over one-fourth of lid margin, full thickness |
| 68700 | Plastic repair of canaliculi |
| 68720 | Dacryocystorhinostomy (DCR) |
Key Distinction — 67930 vs. 67935: CPT 67930 is used when the full-thickness eyelid wound or defect involving the lid margin encompasses one-fourth or less (25% or less) of the total horizontal lid margin length. These smaller defects can often be repaired with a pentagonal wedge excision and direct layered closure without adjunctive flaps or grafts. CPT 67935 applies when the defect is greater than one-fourth (more than 25%) of the total horizontal lid margin. This threshold triggers the use of this higher-complexity code regardless of the specific reconstructive technique employed, as long as vitrectomy involves the lid margin, tarsus, and/or palpebral conjunctiva as a full-thickness repair.
Key Distinction — 67935 vs. 67961/67966: CPT 67930/67935 are used for traumatic lacerations and recent wounds requiring suture repair. CPT 67961/67966 are used for excision and repair — typically post-tumor excision defects where tissue is deliberately removed (e.g., after Mohs surgery for basal cell carcinoma of the eyelid) and then reconstructed. The distinction between “repair of a wound” (67930/67935) and “excision and repair” (67961/67966) is etiology-based. For Mohs defect reconstructions, use the 67961/67966 series, not the 67930/67935 series.
Key Distinction — 67935 vs. 67971/67973/67974: CPT 67971/67973/67974 specifically describe full-thickness reconstruction by transfer of a tarsoconjunctival flap from the opposing eyelid (i.e., a formal Hughes or Cutler-Beard type procedure documented as a staged tarsoconjunctival flap transfer). If the operative report explicitly documents a tarsoconjunctival flap from the opposing eyelid as the primary reconstructive technique, these codes may be more appropriate than 67935. Review the operative report carefully to determine which code family best reflects the documented technique.
ICD-10-CM Diagnosis Codes
Traumatic Eyelid Lacerations
| ICD-10-CM | Description |
|---|---|
| S01.111A | Laceration without foreign body of right eyelid and periocular area, initial encounter |
| S01.111D | Laceration without foreign body of right eyelid and periocular area, subsequent encounter |
| S01.112A | Laceration without foreign body of left eyelid and periocular area, initial encounter |
| S01.112D | Laceration without foreign body of left eyelid and periocular area, subsequent encounter |
| S01.119A | Laceration without foreign body of unspecified eyelid and periocular area, initial encounter |
| S01.121A | Laceration with foreign body of right eyelid and periocular area, initial encounter |
| S01.122A | Laceration with foreign body of left eyelid and periocular area, initial encounter |
| S05.31XA | Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter |
| S05.32XA | Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter |
Eyelid Neoplasms (Post-Excision Reconstruction)
| ICD-10-CM | Description | HCC |
|---|---|---|
| C44.101 | Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus | HCC 12 |
| C44.102 | Unspecified malignant neoplasm of skin of right eyelid, including canthus | HCC 12 |
| C44.109 | Unspecified malignant neoplasm of skin of left eyelid, including canthus | HCC 12 |
| C44.111 | Basal cell carcinoma of skin of unspecified eyelid, including canthus | HCC 12 |
| C44.112 | Basal cell carcinoma of skin of right eyelid, including canthus | HCC 12 |
| C44.119 | Basal cell carcinoma of skin of left eyelid, including canthus | HCC 12 |
| C44.121 | Squamous cell carcinoma of skin of unspecified eyelid, including canthus | HCC 12 |
| C44.122 | Squamous cell carcinoma of skin of right eyelid, including canthus | HCC 12 |
| C44.129 | Squamous cell carcinoma of skin of left eyelid, including canthus | HCC 12 |
| C44.131 | Sebaceous cell carcinoma of skin of unspecified eyelid, including canthus | HCC 12 |
| C44.132 | Sebaceous cell carcinoma of skin of right eyelid, including canthus | HCC 12 |
| C49.0 | Malignant neoplasm of connective and soft tissue of head, face, and neck | HCC 11 |
| D04.11 | Carcinoma in situ of skin of right eyelid, including canthus | No HCC |
| D04.12 | Carcinoma in situ of skin of left eyelid, including canthus | No HCC |
Eyelid Structural Abnormalities Requiring Repair
| ICD-10-CM | Description |
|---|---|
| H02.811 | Retained foreign body in right upper eyelid |
| H02.812 | Retained foreign body in right lower eyelid |
| H02.813 | Retained foreign body in right eye, unspecified eyelid |
| H02.814 | Retained foreign body in left upper eyelid |
| H02.815 | Retained foreign body in left lower eyelid |
| H02.201 | Unspecified lagophthalmos right upper eyelid (complication of prior repair) |
| H02.001 | Entropion of right upper eyelid (if present as secondary diagnosis) |
| H02.101 | Ectropion of right upper eyelid (if present as secondary diagnosis) |
| H02.411 | Mechanical ptosis of right upper eyelid (if related to defect/repair) |
Laterality and Eyelid Specificity: ICD-10-CM eyelid codes require laterality (right vs. left) AND in many categories the specific eyelid (upper vs. lower). Always assign the most specific code available. For traumatic lacerations in the acute setting, the 7th character “A” (initial encounter) is used at the time of the operative repair. Subsequent encounters (e.g., follow-up within the global period) use “D” (subsequent encounter). Sequelae of eyelid trauma use “S.”
External Cause Codes: For traumatic eyelid lacerations, external cause codes (W, X, Y categories) should be reported as secondary diagnoses to capture the mechanism of injury (e.g., W26.0XXA — contact with knife, initial encounter; W45.8XXA — other foreign body or object entering through skin).
HCC Relevance
CPT 67935 is a surgical procedure code and does not itself map to an HCC. However, associated diagnosis codes have HCC implications:
| ICD-10-CM | HCC Assignment | Notes |
|---|---|---|
| C44.111-C44.129 | HCC 12 | Eyelid skin malignancy (BCC, SCC) — moderate RAF weight |
| C44.131-C44.139 | HCC 12 | Sebaceous cell carcinoma of eyelid — moderate RAF weight |
| C49.0 | HCC 11 | Soft tissue malignancy of head and neck — higher RAF weight |
| D04.1x | No HCC | Carcinoma in situ — not HCC-mapped |
| H33.x | No HCC | Retinal detachment — not directly HCC-mapped |
HCC Coding Note: Eyelid malignancies, particularly sebaceous cell carcinoma of the eyelid (C44.131/132) — a highly malignant tumor with significant metastatic potential that arises from meibomian glands — map to HCC 12. While basal cell carcinoma of the eyelid is the most common eyelid malignancy, squamous cell carcinoma and sebaceous carcinoma carry greater systemic significance. Ensuring that the histologic subtype is clearly documented and coded (rather than defaulting to C44.101 “unspecified”) improves both clinical communication and risk adjustment accuracy.
wRVU and Reimbursement
| Metric | Value |
|---|---|
| Work RVU (wRVU) | 10.03 |
| Total RVU (facility, national avg) | ~14.50 |
| Total RVU (non-facility / office / ASC) | ~18.00-20.00+ |
| Global Period | 90 days |
| Assistant Surgeon Payable | Yes — modifier -80, -82, or -AS |
| Co-Surgeon | Generally not applicable for routine cases; may apply in complex orbital/facial trauma with multiple surgical specialties |
| Bilateral | Bilateral eyelid repair rare; if performed, report with modifier -50 or separate line items with -RT/-LT |
| Modifier -50 | Applicable if truly bilateral simultaneous repair |
| Teaching Physician | Modifier -GC in academic settings |
| Anesthesia CPT | 00140 — anesthesia for procedures on eye; not otherwise specified |
| Performed in Office Setting | Yes, for select cases under local anesthesia with appropriate surgical setup |
Assistant Payable Detail: CPT 67935 is assistant-payable given the complexity of full-thickness lid margin reconstruction involving more than 25% of the lid. Complex reconstructions such as the Hughes procedure, Cutler-Beard flap, or Mustardé cheek rotation genuinely benefit from an assistant surgeon for retraction, graft harvesting, and simultaneous layered closure. Medicare and most commercial payers recognize assistant surgeon payment for this code. In a teaching setting, residents or fellows functioning as first assistants should be documented accordingly in the operative report.
Non-Facility vs. Facility RVU Differential: Like many ophthalmic and oculoplastic procedures, CPT 67935 has a meaningfully higher total RVU in the non-facility setting (office or ASC) compared to the hospital outpatient or inpatient setting. This is because the non-facility PE RVU includes practice expense for equipment, supplies, and staff that the facility separately bills when the procedure is performed in a hospital or ASC. Most oculoplastic eyelid reconstructions are performed in an ASC or office-based surgical suite.
MS-DRG Assignment
Full-thickness eyelid repair is overwhelmingly performed in the outpatient or ASC setting. Inpatient admission is uncommon and typically occurs only in the context of major facial trauma, oncologic resection requiring complex head and neck team involvement, or significant systemic comorbidities requiring monitoring. When an inpatient claim is generated, MS-DRG assignment is driven by the principal diagnosis and ICD-10-PCS procedure coding.
| MS-DRG | Description | Type |
|---|---|---|
| 116 | Intraocular Procedures with CC/MCC | Surgical |
| 117 | Intraocular Procedures without CC/MCC | Surgical |
| 124 | Other Disorders of the Eye with MCC | Medical |
| 125 | Other Disorders of the Eye without MCC | Medical |
| 573 | Skin Graft and/or Debridement Except Hand for Musculoskeletal Tissue Disorders with MCC | Surgical (if skin graft drives the DRG) |
| 574 | Skin Graft and/or Debridement Except Hand for Musculoskeletal Tissue Disorders with CC | Surgical |
| 575 | Skin Graft and/or Debridement Except Hand for Musculoskeletal Tissue Disorders without CC/MCC | Surgical |
MS-DRG Coding Note: Eyelid procedures may group to either the eye DRGs (116/117 or 124/125) or the skin/soft tissue DRGs depending on the principal diagnosis, the ICD-10-PCS procedure codes assigned, and whether a skin graft procedure triggers a separate DRG. If the primary operative procedure is eyelid repair under an eye-specific ICD-10-PCS code, the eye surgical DRGs (116/117) typically apply. The presence of MCC conditions significantly impacts DRG weight. In trauma cases with multiple facial fractures, the facial fracture DRGs (186/187) may be triggered instead, depending on which diagnosis is sequenced as principal.
ICD-10-PCS Equivalents (Inpatient Facility Coding)
For inpatient cases, ICD-10-PCS codes are required to capture the full-thickness eyelid repair. The root operation and approach vary depending on the reconstructive technique.
| ICD-10-PCS Code | Description | Notes |
|---|---|---|
| 08Q03ZZ | Repair of Right Upper Eyelid, Percutaneous Approach | Direct repair of upper lid defect |
| 08Q13ZZ | Repair of Right Lower Eyelid, Percutaneous Approach | Direct repair of lower lid defect |
| 08Q23ZZ | Repair of Left Upper Eyelid, Percutaneous Approach | Direct repair of upper lid defect, left |
| 08Q33ZZ | Repair of Left Lower Eyelid, Percutaneous Approach | Direct repair of lower lid defect, left |
| 08R03KZ | Replacement of Right Upper Eyelid with Nonautologous Tissue Substitute, Percutaneous Approach | If graft/flap tissue used |
| 08R13KZ | Replacement of Right Lower Eyelid with Nonautologous Tissue Substitute, Percutaneous Approach | If graft/flap tissue used |
| 08RP0ZZ | Replacement of Right Conjunctiva with No Device, External Approach | Palpebral conjunctival reconstruction |
| 08RQ0ZZ | Replacement of Left Conjunctiva with No Device, External Approach | Palpebral conjunctival reconstruction, left |
| 0HR0XZZ | Replacement of Scalp/Face Skin, External Approach (skin graft component) | If FTSG from distant site |
ICD-10-PCS Root Operation Guidance: The choice of root operation is critical and must match the operative technique:
- Repair (Q) — used when the eyelid is restored to its normal structure without replacement of tissue; direct suture repair of lacerations
- Replacement (R) — used when the eyelid tissue is replaced with a substitute (graft, flap from a different body part); appropriate when a tarsoconjunctival flap from the opposing eyelid or a skin graft from a distant donor site is the primary reconstructive material
- Reposition (S) — used when tissue is moved to a new location without cutting it free (e.g., local advancement flap that remains pedicled)
- Transfer (X) — used when a pedicled flap from a nearby site is moved to a new location while maintaining its vascular pedicle
Coding Examples
Example 1 — Traumatic Full-Thickness Eyelid Laceration with Lid Margin Involvement, Right Lower Lid
A 34-year-old male presents to the emergency department following an assault with a broken bottle. He has a full-thickness laceration of the right lower eyelid at the 5 mm medial to the lateral canthus extending to the lid margin and measuring approximately 12 mm horizontally, involving approximately 45% of the total lower lid margin. The laceration extends through skin, orbicularis, tarsus, and palpebral conjunctiva. Canalicular involvement is ruled out on examination with irrigation. The patient is taken to the OR for repair under MAC anesthesia.
The surgeon performs layered closure: palpebral conjunctiva and posterior tarsal plate are reapproximated with interrupted 5-0 polyglactin sutures, the lid margin is repaired with 5-0 silk sutures at the gray line, lash line, and meibomian gland orifice level, and the anterior lamella is closed with interrupted 6-0 nylon skin sutures.
CPT Code:
- 67935-RT — Repair of eyelid involving lid margin, tarsus, and/or palpebral conjunctiva; over one-fourth of lid margin, right eye
ICD-10-CM:
- S01.111A — Laceration without foreign body of right eyelid and periocular area, initial encounter
- External cause code (e.g., Y04.0XXA — Assault by unarmed brawl or fight, initial encounter)
- W25.XXXA — Contact with sharp glass, initial encounter (if applicable based on documentation)
ICD-10-PCS (Inpatient):
- 08Q13ZZ — Repair of Right Lower Eyelid, Percutaneous Approach
Example 2 — Post-Mohs Reconstruction of Lower Eyelid After Basal Cell Carcinoma Excision
A 72-year-old female undergoes Mohs micrographic surgery (performed by dermatology) for a 14 mm basal cell carcinoma of the right lower eyelid. After Mohs clearance, the resulting full-thickness defect involves approximately 60% of the lower lid margin, extending through the tarsus and palpebral conjunctiva. The oculoplastic surgeon performs a modified Hughes tarsoconjunctival flap from the right upper eyelid to reconstruct the posterior lamella, combined with a retroauricular full-thickness skin graft to reconstruct the anterior lamella in a single-stage procedure.
CPT Codes — Oculoplastic Surgeon (Stage 1):
- 67966-RT — Excision and repair of eyelid, over one-fourth of lid margin, full thickness, right eye
Note: Because this is a post-tumor excision reconstruction (the defect was created by deliberate excision), CPT 67966 (excision and repair) rather than 67935 (repair of wound/laceration) is the appropriate code. This is a critical distinction. The Mohs surgeon separately bills CPT 17311-17315 for the excision. The oculoplastic surgeon bills 67966 for the reconstruction. These are separate services by separate physicians and are NOT unbundling.
CPT Codes — Second Stage (Flap Division, ~6 weeks later):
- 67975 — Reconstruction of eyelid, full thickness; second stage
ICD-10-CM:
- C44.112 — Basal cell carcinoma of skin of right eyelid, including canthus
Example 3 — Traumatic Dog Bite with Full-Thickness Upper Eyelid Laceration Involving Canaliculus
A 6-year-old child presents following a dog bite to the left periocular region. Examination reveals a full-thickness laceration of the left upper eyelid involving approximately 35% of the upper lid margin with extension into the medial canthal area, lacer of the lower canaliculus, and avulsion of medial canthal tissue. The patient is taken to the OR under general anesthesia.
The surgeon performs full-thickness lid margin repair (layered closure of conjunctiva, tarsus, and skin), medial canthal tendon reattachment with transnasal wiring, and canalicular intubation with a monocanalicular silicone stent.
CPT Codes:
- 67935-LT — Full-thickness eyelid repair, over one-fourth of lid margin, left upper eyelid
- 68700-LT — Plastic repair of canaliculi (canalicular laceration repair with intubation; separately reportable as the canalicular system is a distinct anatomic structure requiring a separate operative technique and is not bundled into 67935)
ICD-10-CM:
- S01.112A — Laceration without foreign body of left eyelid and periocular area, initial encounter
- S01.532A — Open bite of left cheek and temporomandibular area, initial encounter (if bite involves cheek)
- W54.0XXA — Bitten by dog, initial encounter
Example 4 — Incorrect Code Selection Scenario (Audit Red Flag)
A 55-year-old male undergoes excision of a 4 mm basal cell carcinoma of the right lower eyelid by an ophthalmologist in the office setting. The excision results in a small defect at the lid margin involving approximately 15% of the lower lid margin. The wound is closed directly with layered sutures (conjunctiva, tarsus, skin) under local anesthesia. The surgeon bills CPT 67935.
Incorrect: 67935 — This code requires defect involvement of MORE than one-fourth (>25%) of the lid margin. A 15% defect does not meet the threshold. Correct: 67930 — Repair of eyelid involving lid margin; not involving one-fourth of lid margin.
Also consider:
- If this was an excision with repair (tumor removed by the same surgeon who then reconstructed), the correct code family is 67961 (excision and repair, not more than one-fourth of lid margin) rather than 67930 (which describes repair of a wound/laceration). The 67961/67966 series captures both the excision and repair in one code; the excision is not separately reported when the same surgeon performs both excision and repair.
Example 5 — Bilateral Eyelid Repair After Thermal Burn
A 28-year-old male sustains partial and full-thickness thermal burns to the bilateral eyelids and periorbital region in a house fire. After initial wound management and burn care, he is taken to the OR for bilateral full-thickness eyelid margin repair with tarsoconjunctival reconstruction, involving approximately 30-35% of the upper lid margin bilaterally.
CPT Codes:
- 67935-RT — Full-thickness right upper eyelid repair, over one-fourth of lid margin
- 67935-LT — Full-thickness left upper eyelid repair, over one-fourth of lid margin
- (Do NOT use modifier -50; bilateral eyelid procedures on different sides should be reported as separate line items with laterality modifiers to allow payer processing; modifier -50 is acceptable with some payers but -RT/-LT is more specific and less likely to be denied)
ICD-10-CM:
- T26.21XA — Burn of eyelid and periocular area, right eye, initial encounter
- T26.22XA — Burn of eyelid and periocular area, left eye, initial encounter
- T31.0 — Burns involving less than 10% of body surface area (if applicable)
- External cause (e.g., X00.0XXA — Exposure to flames in uncontrolled building fire)
Documentation Requirements
To support CPT 67935, the operative report must contain:
- Diagnosis and etiology — explicitly state whether the defect is traumatic (laceration, bite, burn) or post-excision (tumor removal); the etiology drives whether 67930/67935 or 67961/67966 is the appropriate code family
- Laterality — which eye (right vs. left) and which eyelid (upper vs. lower) was repaired
- Defect dimensions — horizontal extent of the lid margin defect in millimeters AND as a percentage of the total lid margin; must document that defect involves MORE than 25% of the lid margin to support 67935 over 67930
- Full-thickness involvement — explicit documentation that the defect traversed the full thickness of the eyelid from anterior skin surface to posterior palpebral conjunctiva, including involvement of tarsus
- Lid margin involvement — must document involvement of the free margin of the eyelid (gray line, meibomian orifices, lash line)
- Reconstructive technique — detail the specific technique(s) used (direct closure, Tenzel flap, Hughes flap, skin graft, etc.) and the structures reconstructed
- Layered closure details — document suture materials, technique, and layer-by-layer repair of posterior lamella, lid margin, and anterior lamella
- Canalicular assessment — document whether the canalicular system was assessed for involvement; if canalicular repair was performed, this must be documented to support separate reporting of 68700
- Anesthesia type — local, MAC, or general
- Complexity factors — if adjunctive procedures were performed (cantholysis, canthopexy, graft harvest), these should be individually documented
Clinical Notes for Coders
-
The 25% threshold is the single most important coding distinction between 67930 and 67935. Because eyelid widths are not standardized, coders should look for explicit surgeon documentation of the percentage of lid margin involved, or calculate based on documented defect size vs. the expected lid width for that patient. A defect described as “8 mm of a 28 mm lower lid margin” is approximately 28.5% — supporting 67935.
-
Sebaceous cell carcinoma of the eyelid deserves special attention from coders. Unlike basal cell or squamous cell carcinoma, sebaceous carcinoma has high rates of pagetoid spread along the conjunctival surface, multicentric origin, and risk of orbital extension and regional lymph node metastasis. It is often confused clinically with a chalazion, causing diagnostic delays. When sebaceous carcinoma is the underlying diagnosis driving eyelid reconstruction, ensure the ICD-10-CM code (C44.131/132/139) is assigned with full specificity, as it carries HCC 12 designation and significant clinical implications.
-
Hughes procedure (tarsoconjunctival flap) and Cutler-Beard procedure are two-stage reconstructions. Stage 1 (flap creation and inset) is reported at the first operative session. Stage 2 (flap division and inset refinement) occurs 4-8 weeks later and is reported separately (CPT 67975 for Hughes second stage). If the second-stage procedure falls within the 90-day global period of the Stage 1 repair, modifier -58 (staged procedure) must be appended to the Stage 2 claim to allow separate reimbursement.
-
Canalicular repair (CPT 68700) is separately reportable from 67935 when a medial lid laceration involves the canalicular system and formal intubation with silicone stent (monocanalicular or bicanalicular) is performed. The canalicular system and the eyelid margin are distinct anatomic structures with distinct CPT codes. Do not bundle 68700 into 67935.
-
Skin grafts harvested from a non-adjacent donor site (retroauricular, supraclavicular, contralateral upper eyelid skin) may be separately reportable with full-thickness skin graft codes (CPT 15260-15261). However, NCCI edits and payer policy vary. Some payers consider the skin graft bundled into the reconstruction code; others allow separate reporting with modifier -59 when the graft is from a truly separate and distant donor site. Review payer-specific policies and NCCI edits carefully.
-
Tarsoconjunctival graft from the ipsilateral or contralateral upper eyelid used as a free graft (not a pedicled flap) for posterior lamellar reconstruction is generally considered bundled into the reconstruction code (67935 or 67966). The graft harvest is part of the reconstructive effort and is not a separately defined surgical service.
-
Modifier -78 (unplanned return to the OR during global period) applies if a patient returns within the 90-day global period for a complication of the original repair, such as wound dehiscence, infection, or graft failure requiring surgical intervention.
-
Ophthalmic plastic vs. general ophthalmology billing: CPT 67935 is commonly billed by oculoplastic surgeons (typically fellowship-trained ophthalmologists), but may also be billed by general ophthalmologists, plastic surgeons, facial plastic surgeons (ENT), and oral/maxillofacial surgeons when they perform eyelid margin repair. The code is specialty-neutral and the same CPT applies regardless of the surgeon’s training background. However, payers may request documentation of medical necessity and operative complexity for high-value claims.