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Official Description

Blepharotomy, drainage of abscess, eyelid

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

A blepharotomy is a surgical procedure specifically designed to address the presence of an abscess in the eyelid. An abscess is a localized collection of pus that can occur due to infection, leading to swelling, pain, and discomfort in the affected area. The procedure involves several critical steps to ensure effective drainage of the abscess. Initially, the skin over the abscess is thoroughly cleansed to minimize the risk of introducing additional bacteria during the procedure. Following this, a local anesthetic is administered to numb the area, ensuring that the patient experiences minimal discomfort during the incision and drainage process. The surgeon then makes a precise incision at the site where the abscess is most prominent, often referred to as the area of greatest fluctuance, which indicates the location where the pus has accumulated. This incision allows for the effective drainage of the abscess, alleviating pressure and pain associated with the condition. Overall, the blepharotomy procedure is a targeted intervention aimed at resolving eyelid abscesses and restoring normal function and appearance to the eyelid.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The blepharotomy procedure is indicated for the following conditions:

  • Eyelid Abscess The primary indication for performing a blepharotomy is the presence of an abscess in the eyelid, which is characterized by localized swelling, redness, and pain due to infection.

2. Procedure

The blepharotomy procedure involves several key steps to ensure effective drainage of the eyelid abscess:

  • Step 1: Cleansing the Skin The first step in the procedure is to thoroughly cleanse the skin overlying the abscess. This is crucial to reduce the risk of infection and to prepare the area for the incision.
  • Step 2: Administering Local Anesthetic After cleansing, a local anesthetic is injected into the area surrounding the abscess. This step is essential to numb the region, ensuring that the patient experiences minimal discomfort during the procedure.
  • Step 3: Making the Incision Once the area is anesthetized, the surgeon makes an incision over the site of greatest fluctuance, which is the area where the abscess is most prominent. This incision allows for direct access to the abscess.
  • Step 4: Draining the Abscess Following the incision, the surgeon drains the pus from the abscess. This step is critical for relieving pressure and alleviating pain associated with the infection.

3. Post-Procedure

After the blepharotomy procedure, post-operative care is essential for optimal recovery. The patient may be advised to keep the area clean and dry, and to follow any specific instructions provided by the healthcare provider regarding wound care. Monitoring for signs of infection, such as increased redness, swelling, or discharge, is also important. The expected recovery time may vary depending on the individual, but most patients can anticipate a gradual return to normal activities as the area heals. Follow-up appointments may be scheduled to assess the healing process and to ensure that no complications arise.

Short Descr BLEPHAROTOMY DRG ABSC EYELID
Medium Descr BLEPHAROTOMY DRAINAGE ABSCESS EYELID
Long Descr Blepharotomy, drainage of abscess, eyelid
Status Code Active Code
Global Days 010 - Minor Procedure
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) 1 - Statutory 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 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6C - Minor procedures - other (Medicare fee schedule)
MUE 2
CCS Clinical Classification 19 - Other therapeutic procedures on eyelids, conjunctiva, cornea
RT Right side (used to identify procedures performed on the right side of the body)
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).
E4 Lower right, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
LT Left side (used to identify procedures performed on the left side of the body)
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.)
E1 Upper left, eyelid
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.
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).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
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.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
CG Policy criteria applied
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
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG Ambulatory surgical center (asc) facility service
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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2025-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
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