• Exploration of the Medial Upper Lid


    During blepharoplasty, our surgeons perform an exploration of the medial upper lid for possible foreign body.  There was no foreign body but excessive scar tissue. They debulked and biopsied the scar tissue. What CPT code is appropriate to bill for the exploration?

    Answer:
    There is no defined CPT for scar tissue exploration in the eyelid. Because this was performed during blepharoplasty no additional code would be billed.

    You can submit the biopsy but should wait and attach the diagnosis after receiving the e pathology results.

    Additional coding competency resources can be found in Coding Coach Complete Ophthalmic Coding Reference.