© Copyright 2025 American Medical Association. All rights reserved.
Blepharoplasty, lower eyelid with extensive herniated fat pad, as described by CPT® Code 15821, is a surgical procedure aimed at correcting aesthetic and functional issues associated with the lower eyelids. This procedure specifically addresses the presence of herniated fat pads, which can contribute to a puffy appearance under the eyes, often leading to a tired or aged look. The surgery involves making an incision in the conjunctiva of the lower eyelid to access the underlying fat pad. The procedure may also involve severing the tendon on the lateral aspect of the eyelid to enhance visibility and access to the fat pad. The surgeon dissects the herniated fat pad from surrounding tissues, allowing for its removal or repositioning. A common technique used in this procedure is the creation of a subperiosteal tunnel, which facilitates the transposition of the fat to the tear trough area over the cheekbone, thereby improving the contour and appearance of the lower eyelid. The procedure concludes with the excision of a wedge of eyelid tissue to tighten the lower lid, followed by securing the new tendon to the periosteum of the orbital rim and closing the incision with running sutures. This comprehensive approach not only enhances the aesthetic outcome but also addresses any functional impairments related to the lower eyelid structure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 15821 is indicated for patients presenting with specific conditions related to the lower eyelids. These indications include:
The procedure for CPT® Code 15821 involves several detailed steps to effectively address the issues associated with the lower eyelid. These steps include:
After the completion of the blepharoplasty procedure, patients can expect specific post-operative care and considerations. It is important to monitor for any signs of complications, such as excessive swelling or infection. Patients are typically advised to keep the surgical area clean and may be prescribed topical ointments to aid in healing. Cold compresses can be applied to reduce swelling and discomfort in the initial days following surgery. Follow-up appointments are essential to assess the healing process and ensure that the eyelid is recovering properly. Patients should also be informed about potential changes in sensation around the eyelid area and the importance of avoiding strenuous activities during the initial recovery phase. Overall, adherence to post-procedure instructions is crucial for achieving optimal results and minimizing risks.
| Short Descr | BLEPHARP LWR EYELID FAT PAD | Medium Descr | BLEPHAROPLASTY LOWER EYELID W/HERNIATED FAT PAD | Long Descr | Blepharoplasty, lower eyelid; with extensive herniated fat pad | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6A - Minor procedures - skin | MUE | 1 | CCS Clinical Classification | 19 - Other therapeutic procedures on eyelids, conjunctiva, cornea |
| E4 | Lower right, eyelid | E2 | Lower left, eyelid | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | E1 | Upper left, eyelid | E3 | Upper right, eyelid | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | SG | Ambulatory surgical center (asc) facility service | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.