CPT Code 67904

CPT code 67904 is for surgical repair of an eyelid defect.

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What is CPT Code 67904

CPT code 67904 is used to describe a surgical procedure focused on repairing an eyelid defect. This code specifically covers the correction of ptosis, which is a condition where the upper eyelid droops over the eye. The repair involves techniques to elevate the eyelid to improve vision and appearance, typically by shortening the muscles or tendons responsible for lifting the eyelid.

Does CPT 67904 Need a Modifier?

CPT code 67904, which pertains to the repair of an eyelid defect, may require the use of specific modifiers to accurately represent the circumstances of the procedure for billing and reimbursement purposes. Here is an ordered list of potential modifiers that could be applicable, depending on the specific details of the surgical procedure performed:

1. -RT (Right Side) and -LT (Left Side): These modifiers are used to indicate which eyelid was operated on if the procedure was performed on only one eyelid.

2. -50 (Bilateral Procedure): If the repair was performed on both eyelids during the same operative session, this modifier should be used to indicate a bilateral procedure.

3. -51 (Multiple Procedures): This modifier is used if multiple procedures were performed during the same surgical session. It helps in adjusting the reimbursement for the additional procedures, which are generally paid at a lower rate.

4. -22 (Increased Procedural Services): If the procedure required a greater effort than typically required, this modifier could be added to indicate that the procedure was more complex or time-consuming than usual.

5. -52 (Reduced Services): If the procedure was partially reduced or eliminated at the physician's discretion, this modifier would be appropriate to indicate that the service provided was less than usually required.

6. -59 (Distinct Procedural Service): This modifier is used to indicate that procedures that are normally bundled together were performed in separate and distinct circumstances. It helps to prevent incorrect bundling and ensure proper reimbursement.

7. -76 (Repeat Procedure by Same Physician): If the same physician had to repeat the eyelid repair procedure during the same session, this modifier would be necessary.

8. -78 (Unplanned Return to the Operating/Procedure Room): Used if a return to the operating room was required for a related procedure during the postoperative period.

9. -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): This modifier is used if another procedure, which is not related to the eyelid repair, was performed during the postoperative period.

Each of these modifiers serves to provide specific details that affect how the procedure is billed and reimbursed, ensuring that the claims are accurate and reflect the actual services provided. It's important for healthcare providers to use these modifiers correctly to avoid delays in payment or denials of claims.

CPT Code 67904 Medicare Reimbursement

CPT code 67904, which pertains to the repair of an eyelid defect, is generally reimbursable by Medicare. However, the specific coverage and reimbursement amount can vary based on the Medicare Administrative Contractor (MAC) that services your geographical area, as well as the specific circumstances and medical necessity of the procedure.

To determine the exact reimbursement amount for CPT code 67904, it is advisable to consult the fee schedule provided by the local MAC. This schedule will provide detailed information on the allowable charges for this procedure in your specific region. Additionally, ensure that the documentation supports the medical necessity of the procedure to facilitate appropriate reimbursement from Medicare.

Are You Being Underpaid for 67904 CPT Code?

Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately detecting underpayments. With the capability to scrutinize contracts and identify discrepancies down to specific CPT codes, such as 67904 for eyelid defect repairs, RevFind ensures that each claim is fully compensated according to your payer agreements. Schedule a demo today to see how RevFind can help secure the payments you are entitled to for every service rendered.

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