Crystal's MCW Coder Hub🧬 ICD-10 CM H02.431 - Paralytic Ptosis of Right Eyelid
Short Description
H02.431 is used for paralytic ptosis of the right eyelid - drooping of the right upper eyelid caused by neurogenic weakness or paralysis of the levator palpebrae superioris muscle or its nerve supply (CN III, CN VII, or sympathetic innervation). This reflects functional impairment rather than mechanical or myogenic causes.
Key distinction: Paralytic ptosis is neurogenic; differs from mechanical ptosis (H02.411) and myogenic ptosis (H02.421).
Full Description & Clinical Context
Ptosis (blepharoptosis) is a drooping of the upper eyelid in primary gaze. When the droop is caused by paralysis or weakness of the levator palpebrae superioris muscle or its innervation, it is classified as paralytic ptosis. This differs from mechanical causes (tissue excess, loose aponeurosis) or myogenic causes (muscle disease).
H02.431 specifically indicates:
- Ptosis affecting the RIGHT upper eyelid
- Neurogenic etiology - CN III (oculomotor) palsy, CN VII (facial) palsy, Horner syndrome (sympathetic dysfunction), myasthenia gravis, or other neural dysfunction
- Functional impairment of the levator muscle or its innervation
Clinical presentation:
- Drooping of right upper eyelid in primary gaze
- Visual field obstruction (if severe, can block central vision)
- Compensatory head posture (chin up, brow elevation) to improve vision
- Associated symptoms depending on etiology:
- CN III palsy: eye down and out, mydriasis, other extraocular muscle involvement
- CN VII palsy: facial weakness, inability to close eye, Bell’s phenomenon
- Horner syndrome: miosis, anhidrosis, apparent ptosis (mild)
- Myasthenia gravis: fatigue worse with activity, may be bilateral and variable
Etiologies of neurogenic ptosis:
- CN III (oculomotor) palsy - most common cause of complete ptosis
- CN VII (facial) palsy - mild ptosis from decreased tone
- Horner syndrome - mild ptosis from loss of Müller’s muscle innervation
- Myasthenia gravis - variable, fatigable ptosis
- Stroke or CNS lesions affecting CN nuclei
- Peripheral nerve injuries
- Diabetic neuropathy
- Trauma or surgical injury
Code Details
- Code set: ICD-10-CM
- Full code: H02.431
- Description: Paralytic ptosis of right eyelid
- Parent code: H02.43 - Paralytic ptosis of eyelid
- Category: H02 - Other disorders of eyelid
- Code type: Billable/specific diagnosis code
- Laterality: Right eyelid (specified)
- Synonyms: Neurogenic ptosis right eye, CN III palsy with ptosis, paralytic blepharoptosis right
Excludes1 at H02:
- Congenital ptosis or congenital malformations of eyelid (Q10.0-Q10.3)
Excludes2 at H02:
- Mechanical complications of contact lens (H18.5-)
- Problems associated with artificial eye (Z97.0)
Related / Variant Codes (H02.4 - Ptosis of Eyelid Family)
| Code | Description | Laterality | Etiology | When to Use |
|---|---|---|---|---|
| H02.40 | Unspecified ptosis of eyelid | Unspecified | Unknown/NOS | Type and location not specified |
| H02.401 | Unspecified ptosis of right eyelid | Right | Unknown | Right ptosis, cause unspecified |
| H02.402 | Unspecified ptosis of left eyelid | Left | Unknown | Left ptosis, cause unspecified |
| H02.409 | Unspecified ptosis of unspecified eyelid | Unspecified | Unknown | Location and cause unknown |
| H02.41 | Mechanical ptosis of eyelid | Various | Mechanical (tissue laxity, aponeurosis dehiscence) | Acquired tissue excess, loose attachments |
| H02.411 | Mechanical ptosis of right eyelid | Right | Mechanical | Right eyelid mechanical cause |
| H02.412 | Mechanical ptosis of left eyelid | Left | Mechanical | Left eyelid mechanical cause |
| H02.413 | Mechanical ptosis of bilateral eyelids | Bilateral | Mechanical | Both eyelids mechanical |
| H02.42 | Myogenic ptosis of eyelid | Various | Myogenic (muscle weakness) | Muscular dystrophy, myasthenia gravis, others |
| H02.421 | Myogenic ptosis of right eyelid | Right | Myogenic | Right eyelid myogenic cause |
| H02.422 | Myogenic ptosis of left eyelid | Left | Myogenic | Left eyelid myogenic cause |
| H02.423 | Myogenic ptosis of bilateral eyelids | Bilateral | Myogenic | Both eyelids myogenic (e.g., myasthenia). |
| H02.43 | Paralytic ptosis of eyelid | Various | Neurogenic/paralytic | Nerve or muscle innervation dysfunction |
| H02.431 | Paralytic ptosis of right eyelid | Right | Neurogenic | CN III/VII palsy, Horner, neural injury ← YOU ARE HERE |
| H02.432 | Paralytic ptosis of left eyelid | Left | Neurogenic | CN III/VII palsy affecting left eye |
| H02.433 | Paralytic ptosis of bilateral eyelids | Bilateral | Neurogenic | Both eyes with CN palsy or systemic neuropathy |
| H02.439 | Paralytic ptosis unspecified eyelid | Unspecified | Neurogenic | Paralytic ptosis, eye not specified |
Critical distinction: The H02.4 hierarchy requires specifying:
- Type of ptosis: mechanical (H02.41) vs myogenic (H02.42) vs paralytic (H02.43)
- Laterality: right (1) vs left (2) vs bilateral (3) vs unspecified (9)
H02.431 vs Other Ptosis Codes (Most Important Distinctions!)
Proper code selection depends on TYPE and LATERALITY:
H02.431 vs H02.411 (Mechanical Ptosis)
| Feature | H02.431 (Paralytic) | H02.411 (Mechanical) |
|---|---|---|
| Etiology | Neurogenic (nerve/muscle innervation) | Mechanical (tissue excess, loose attachments) |
| Muscle function | Levator muscle weak/paralyzed | Levator muscle intact, structural problem |
| Cause examples | CN III palsy, Horner syndrome, CN VII palsy | Dermatochalasis, aponeurosis dehiscence, aging |
| Associated symptoms | Depends on nerve injury (CN III: ophthalmoplegia, mydriasis) | Cosmetic concern, visual field obstruction |
| Treatment | Depends on etiology (glasses, prism, surgery, medical) | Blepharoplasty/ptosis repair |
H02.431 vs H02.421 (Myogenic Ptosis)
| Feature | H02.431 (Paralytic) | H02.421 (Myogenic) |
|---|---|---|
| Etiology | Nerve dysfunction | Muscle dysfunction (primary myopathy) |
| Pattern | Acute onset (CN palsy) or gradual (Horner) | Often gradual, bilateral, fatigable |
| Cause examples | CN III palsy, Horner, CN VII palsy | Myasthenia gravis, muscular dystrophy, CPEO |
| Distinguishing feature | Single nerve territory affected typically | Often systemic muscle involvement |
| When to differentiate | Neuroimaging needed to evaluate nerve lesion | Antibody testing, EMG for myogenic disease |
H02.431 vs H02.401 (Unspecified Ptosis)
| Feature | H02.431 (Paralytic) | H02.401 (Unspecified) |
|---|---|---|
| Type specified | YES - neurogenic/paralytic | NO - cause unknown |
| Use when | Nerve/innervation dysfunction documented | Ptosis present but type/cause unclear |
| Clinical clarity | Clear neurologic etiology | Diagnosis vague or undetermined |
| Query opportunity | If cause vague, query for specific type | Acceptable as fallback when truly unknown |
When to Use H02.431
Use H02.431 when ALL of the following are true:
-
Ptosis (drooping of upper eyelid) is documented:
- “Ptosis,” “drooping eyelid,” “eyelid droop,” “blepharoptosis”
- Right eye/right upper eyelid specifically identified
-
Cause is documented or evident as NEUROGENIC/PARALYTIC:
- CN III (oculomotor) palsy with ptosis
- CN VII (facial) palsy with mild ptosis
- Horner syndrome (sympathetic paralysis of Müller’s muscle)
- Myasthenia gravis with ptosis
- Other nerve palsy, peripheral nerve injury, CNS lesion causing paralysis
- “Paralytic ptosis,” “neurogenic ptosis”
-
RIGHT EYELID is specified as affected (not left, not bilateral, not unspecified)
-
More specific etiology may or may not be documented, but neurogenic mechanism is clear
Typical scenarios:
- Patient with acute CN III palsy presenting with right eye down-and-out, mydriasis, and ptosis
- Chronic Horner syndrome with right-sided mild ptosis, miosis, and anhidrosis
- Post-stroke patient with right facial droop and associated right upper eyelid ptosis
- Myasthenia gravis patient with right ptosis (variable, fatigable)
When NOT to Use H02.431
Avoid H02.431 in these situations:
| Scenario | Use Instead | Rationale |
|---|---|---|
| LEFT eyelid affected, not right | H02.432 | Laterality must be right for H02.431 |
| BOTH eyelids affected | H02.433 | Bilateral ptosis requires different code |
| MECHANICAL ptosis (tissue excess, loose attachments) | H02.411 | Different etiology |
| MYOGENIC ptosis (muscle disease) | H02.421 | Primary muscle dysfunction, not nerve |
| Ptosis type/cause not specified | H02.401 | Unknown/unspecified ptosis |
| Congenital ptosis | Q10.0 | Congenital malformation |
Tip
Critical error to avoid: Using H02.431 for left-sided ptosis (should be H02.432) or mechanical/myogenic ptosis.
Documentation Requirements
MINIMUM documentation to support H02.431:
✅ MUST include:
-
Diagnosis of ptosis explicitly stated:
- “Ptosis,” “drooping eyelid,” “blepharoptosis,” “eyelid droop”
- RIGHT EYE/RIGHT EYELID specified
-
Type is NEUROGENIC/PARALYTIC:
- Documented as “paralytic ptosis” or “neurogenic ptosis,” OR
- Underlying nerve condition documented (CN III palsy, Horner, CN VII palsy, myasthenia, etc.)
-
Clinical findings supporting diagnosis:
- Visual inspection showing right upper lid drooping
- Levator function assessment (weak/absent)
- Associated neurologic findings (ophthalmoplegia, miosis, facial droop, etc. depending on cause)
❌ CANNOT use H02.431 if:
- Left eyelid involved → use H02.432
- Bilateral → use H02.433
- Mechanical or myogenic cause documented → use H02.41 or H02.42
- Type truly unknown → use H02.401
✅ SHOULD document (best practice):
-
Underlying etiology:
- “CN III palsy secondary to [cause: stroke, diabetes, trauma, etc.]”
- “Horner syndrome”
- “Myasthenia gravis”
- “CN VII palsy”
- “Post-surgical nerve injury”
-
Severity/functional impact:
- Degree of lid droop (percentage of pupil/iris covered)
- Visual field obstruction
- Compensatory head posture
- Any associated vision symptoms
-
Levator function:
- “Levator function diminished/absent”
- Measurement in mm (if performing formal testing)
-
Associated features:
- If CN III: pupil size (mydriasis/miosis), extraocular motility limitation
- If CN VII: facial symmetry, eye closure ability, tears
- If Horner: miosis, anhidrosis, apparent vs true ptosis
- If myasthenia: fatigue with activity, improvement with edrophonium/rest
-
Impact on care:
- Functional compromise
- Need for surgical intervention (blepharoplasty, ptosis repair)
- Glasses with prism consideration
HCC Information
- H02.431 does NOT map to a CMS-HCC category in standard Medicare Advantage risk adjustment models
- Eyelid conditions are generally excluded from HCC capture
- No RAF weight or risk scoring impact from this code alone
However, H02.431 is still clinically important for:
- Determining medical necessity for blepharoplasty or ptosis repair procedures
- Supporting higher-level E/M codes when comprehensive ophthalmologic evaluation is needed
- Identifying underlying systemic conditions (stroke, myasthenia, diabetes complications) that DO carry HCC codes
RVU / wRVU Information
- ICD-10-CM codes (including H02.431) do NOT have RVUs or wRVUs
- RVUs attach to CPT codes for procedures and services
- H02.431 supports medical necessity for:
Common CPT Codes Used with H02.431
Evaluation & Ophthalmologic Services:
- 99202-99215 - Office/outpatient E/M (comprehensive exam for ptosis)
- 92002-92004 - Comprehensive eye exams (established patient)
- 92012-92014 - Comprehensive eye exams (new patient)
Surgical Procedures for Ptosis (if indicated):
- 67900 - Repair of blepharoptosis; frontalis muscle technique with suture or other material (mild-moderate paralytic ptosis)
- 67901 - Repair of blepharoptosis; frontalis muscle technique with fascial sling (fascia lata or synthetic) - for severe or CN III palsy
- 67902 - Repair of blepharoptosis; levator resection or advancement
- 67903 - Repair of blepharoptosis; levator resection, external approach
- 67904 - Repair of blepharoptosis; supramuscular transaponeurotic approach
- 67906 - Repair of blepharoptosis; levator muscle transfer
- 67908 - Repair of blepharoptosis; correction of ptosis with adjustable suture
Blepharoplasty (if dermatochalasis/excess skin concurrent):
- 15820 - Blepharoplasty, including repair of blepharoptosis; upper eyelid
- 15821 - Blepharoplasty, including repair of blepharoptosis; lower eyelid
- 15822 - Blepharoplasty, including repair of blepharoptosis; upper and lower eyelids
Neuro-Imaging (for underlying etiology assessment):
- 70553 - MRI brain without and with contrast
- 70540 - MRI orbit/face/neck
- (If CT needed for acute stroke or trauma evaluation)
Common Associated ICD-10-CM Codes
Underlying neurologic conditions:
- G83.4]] - Cauda equina syndrome (if part of broader neuropathy)
- I63.x - Cerebral infarction (stroke causing CN III territory infarct)
- I69.3xx - Sequelae of cerebral infarction (post-stroke CN effects)
- G20-G21 - Parkinson disease (can cause subtle ptosis)
- G70.0 - Myasthenia gravis (can present with ptosis)
- G99.0 - Autonomic neuropathy (Horner component)
- E10-E14 - Diabetes (diabetic CN III palsy)
- G61.0 - Guillain-Barré syndrome (polyneuropathy with CN involvement)
Related eyelid conditions:
- H02.411-H02.413 - Mechanical ptosis (right, left, bilateral)
- H02.421-H02.423 - Myogenic ptosis (if bilateral or mixed)
- H02.432, H02.433 - Paralytic ptosis left or bilateral
- H02.83x - Dermatochalasis (excess eyelid skin)
- H53.xx - Visual disturbances if field obstruction from ptosis
Status/History codes:
- Z90.01 - Absence of eye due to trauma (if eye lost/not available)
- Z97.3 - Glasses and contact lenses (may use prism for ptosis/diplopia)
Clinical Examples
✅ Example 1 - Acute CN III Palsy with Ptosis
SCENARIO:
58-year-old diabetic presents with sudden onset right eye down-and-out,
complete ptosis, and dilated pupil.
Documentation:
"Right CN III palsy with complete ptosis and mydriasis.
Associated with new diabetes diagnosis. MRI brain ordered to rule out
structural lesion. Referral to neuro-ophthalmology."
CODES:
- H02.431 - Paralytic ptosis of right eyelid ✓
- I63.x or unspecified CN III - if stroke
- E11.9 - Type 2 diabetes mellitus
- R27.xxx - Ophthalmoplegia findings (if coded)
RATIONALE:
├─ Right upper eyelid ptosis confirmed
├─ Clearly neurogenic (CN III palsy)
├─ Complete ptosis with mydriasis
└─ H02.431 appropriate for right paralytic ptosis
✅ Example 2 - Horner Syndrome with Mild Ptosis
SCENARIO:
45-year-old presenting for eye care with long-standing right-sided
miosis, anhidrosis, and mild right ptosis.
Documentation:
"Clinical diagnosis: Horner syndrome, right side.
Classic triad: miosis (2 mm difference), anhidrosis, mild ptosis.
Likely congenital vs post-traumatic. Pharmacologic testing pending."
CODES:
- H02.431 - Paralytic ptosis of right eyelid ✓
- G90.2 - Horner syndrome (if primary diagnosis also coded)
RATIONALE:
├─ Right upper eyelid ptosis documented
├─ Neurogenic cause identified (Horner/sympathetic paralysis)
├─ Mild but clinically significant ptosis
└─ H02.431 appropriate
✅ Example 3 - Myasthenia Gravis with Right Ptosis
SCENARIO:
62-year-old with known myasthenia gravis presenting with right ptosis,
fatigable with activity, improves with rest.
Documentation:
"Myasthenia gravis with right upper eyelid ptosis.
Ptosis is variable, worse with fatigue.
Currently on pyridostigmine; considering escalation of immunosuppression."
CODES:
- H02.421 - Myogenic ptosis of right eyelid (if primary myogenic mechanism)
- H02.431 - Paralytic ptosis of right eyelid (if documented as paralytic from NMJ block)
- G70.0 - Myasthenia gravis
CLINICAL NOTE:
└─ Myasthenia gravis is technically myogenic (muscle), NOT neurogenic (nerve).
However, coding guidance may vary by facility.
Use H02.421 (myogenic) if myasthenia is primary dx.
Use H02.431 only if specifically documented as "paralytic" by provider.
❌ Example 4 - WRONG: Left Eyelid Involved
SCENARIO:
Patient with CN VII palsy affecting left side with left eye drooping.
WRONG CODE: H02.431 (right eyelid code)
CORRECT CODE: H02.432 - Paralytic ptosis of LEFT eyelid
WHY WRONG:
├─ H02.431 is ONLY for RIGHT eyelid
├─ Left eye ptosis requires H02.432
└─ Laterality is critical in H02.4 codes!
❌ Example 5 - WRONG: Mechanical Ptosis, Not Neurogenic
SCENARIO:
80-year-old with age-related drooping upper eyelids, no neurologic findings.
Exam shows tissue excess and aponeurosis dehiscence.
WRONG CODE: H02.431
CORRECT CODE: H02.411 - Mechanical ptosis of right eyelid
WHY WRONG:
├─ Cause is MECHANICAL (tissue excess), NOT neurogenic
├─ No nerve/innervation dysfunction
├─ H02.431 would misrepresent etiology
└─ Would affect surgery/treatment planning
Documentation Template (Provider-Friendly)
DIAGNOSIS:
Right paralytic ptosis / Right neurogenic ptosis / Right CN III palsy with ptosis
HISTORY:
- Onset: [date/acute/insidious]
- Course: [sudden onset, gradual]
- Associated symptoms: [diplopia, eye deviation, headache, facial weakness]
- Risk factors: [diabetes, trauma, stroke, family history]
EXAMINATION:
- Visual acuity: [right and left]
- Levator function assessment:
• Levator function: [good/fair/poor/absent]
• Measurement (if formal): ___mm
- Degree of ptosis:
• Percentage of pupil covered: ___%
• Margin reflex distance (MRD): ___mm
- Associated findings:
• Pupil size: [miotic/normal/dilated/], size comparison R vs L
• Extraocular motility: [intact/CN III palsy pattern: down and out]
• Facial symmetry: [symmetric/facial droop on R side]
• Eyes: [can close/cannot close on R]
• Sweating: [normal/anhidrosis on R]
- Other findings: [ptosis improving with upward gaze, worsens with fatigue, etc.]
SYSTEMIC EVALUATION:
- Recent stroke, neurologic event: [Y/N]
- Diabetes: [Y/N; duration, control]
- Myasthenia gravis or other autoimmune: [Y/N]
- Recent head trauma: [Y/N]
- Prior surgery in area: [Y/N]
ASSESSMENT:
Right paralytic ptosis secondary to: [CN III palsy / Horner / CN VII / Myasthenia / Other]
- Etiology: [acute stroke, diabetic CN III, congenital Horner, etc.]
- Severity: [mild/moderate/severe; functional impact]
PLAN:
- Diagnostic workup: [MRI if acute, antibody testing if myasthenia, pharmacologic test if Horner]
- Medical management: [depends on etiology]
- Referral: [neuro-ophthalmology, neurology if indicated]
- Surgical option if: [significant visual obstruction, cosmetic concern, functional compromise]
• Consider ptosis repair (frontalis sling vs levator advancement depending on levator function)
CODING NOTE:
H02.431 - Paralytic ptosis of right eyelid
[Code underlying etiology separately: CN III palsy, Horner, stroke, myasthenia, etc.]
Compliance Checklist
Before assigning H02.431, verify:
- Ptosis (drooping of upper eyelid) is documented
- RIGHT EYE is specified (not left, not bilateral, not unspecified)
- Cause is NEUROGENIC/PARALYTIC:
- Nerve palsy (CN III, CN VII) documented, OR
- Horner syndrome documented, OR
- Myasthenia gravis with ptosis, OR
- Other nerve/innervation dysfunction documented
- NOT mechanical ptosis (H02.411) → use H02.431 only for nerve/innervation cause
- NOT myogenic primary muscle disease → use H02.421 for true myogenic; H02.431 if specified as paralytic
- Underlying etiology is coded separately when applicable (CN palsy, Horner, myasthenia, stroke, etc.)
- Documentation supports surgical intervention consideration if ptosis repair anticipated
Quick Reference Card
ICD-10-CM H02.431 - PARALYTIC PTOSIS OF RIGHT EYELID
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
USE WHEN:
• Right upper eyelid ptosis (drooping)
• Neurogenic/paralytic cause (not mechanical, not purely myogenic)
• Nerve/innervation dysfunction: CN III, CN VII, Horner, etc.
• Documentation specifies RIGHT EYE
AVOID:
• Left eyelid → H02.432
• Bilateral ptosis → H02.433
• Mechanical (tissue excess) → H02.411
• Myogenic muscle disease → H02.421
• Type unspecified → H02.401
ETIOLOGY EXAMPLES:
✓ CN III (oculomotor) palsy
✓ CN VII (facial) palsy
✓ Horner syndrome (sympathetic paralysis)
✓ Myasthenia gravis
✓ Post-stroke CN territory infarct
✓ Traumatic nerve injury
✓ Diabetic CN III palsy
DOCUMENTATION MUST INCLUDE:
☑ "Ptosis" or "eyelid droop" + "right"
☑ Neurogenic/paralytic cause specified
☑ Levator function assessment
☑ Degree of drooping (% pupil covered or MRD)
☑ Associated neurologic findings
HCC:
• None (eyelid conditions not HCC-mapped)
• But underlying etiology (stroke, myasthenia) may carry HCC
CPT PAIRINGS:
• 99213-99215 - Comprehensive exam
• 92002-92004 - Ophthalmology exam
• 67900-67908 - Ptosis repair surgery (if indicated)
• 70553 - Brain MRI (if acute CN evaluation)
RELATED CODES:
• H02.411 - Mechanical ptosis, right
• H02.421 - Myogenic ptosis, right
• H02.432 - Paralytic ptosis, LEFT
• H02.433 - Paralytic ptosis, BILATERAL
• G90.2 - Horner syndrome (underlying cause)
• G70.0 - Myasthenia gravis (underlying cause)
• I63.x - Stroke (underlying cause)
BOTTOM LINE:
H02.431 = Neurogenic right upper eyelid ptosis.
Etiology can vary (CN palsy, Horner, myasthenia, stroke).
Right laterality is KEY - don't confuse with H02.432 (left).
Medical specialty: Ophthalmology, Neuro-Ophthalmology.Billing Note: Medicare Coverage for Ptosis Repair
H02.431 is a covered diagnosis for blepharoplasty/ptosis repair procedures when:
- Paralytic ptosis is documented (H02.431)
- Functional/visual impairment is present and documented
- Surgery is medically necessary (not cosmetic)
- CPT codes billed: 67900, 67901, 67902, 67903, 67904, 67906, 67908 (or blepharoplasty codes if excess skin concurrent)
This code has Group 1 status with CMS and is considered medically necessary when properly documented.
Last Updated: February 11, 2026
For coding reference only - always verify against current ICD-10-CM, official guidelines, payer policies, and ophthalmology documentation standards.
Key Concept: H02.431 is for paralytic (neurogenic) ptosis of the RIGHT eyelid, caused by nerve/innervation dysfunction (CN III palsy, CN VII palsy, Horner syndrome, myasthenia, etc.). Critical to specify RIGHT eyelid (not left or bilateral) and neurogenic mechanism (not mechanical or primary myogenic). Supports medical necessity for comprehensive eye care, neuro-imaging, and potential ptosis repair procedures.