© Copyright 2025 American Medical Association. All rights reserved.
An incisional biopsy of the eyelid skin, as described by CPT® Code 67810, is a surgical procedure aimed at obtaining a tissue sample from a mass or lesion located on the eyelid. This procedure is essential for diagnosing various conditions affecting the eyelid, including tumors, cysts, or other abnormal growths. During the procedure, the area over the planned biopsy site is first disinfected to minimize the risk of infection. A local anesthetic is then administered to ensure the patient experiences minimal discomfort during the biopsy. Following anesthesia, a precise incision is made through the skin of the eyelid, allowing the physician to access the underlying tissue. A sample of the mass or lesion is carefully excised for further analysis. After the tissue sample is obtained, the incision is closed using sutures to promote proper healing. The excised tissue is subsequently sent to a laboratory for histological evaluation, which is reported separately, providing critical information for diagnosis and treatment planning. This procedure is vital for ensuring accurate diagnosis and appropriate management of eyelid conditions.
© Copyright 2025 Coding Ahead. All rights reserved.
The incisional biopsy of the eyelid skin is indicated for various conditions that may require histological examination to determine the nature of a mass or lesion. The following are specific indications for performing this procedure:
The procedure for an incisional biopsy of the eyelid skin involves several critical steps to ensure the safe and effective collection of tissue for diagnostic purposes. The following outlines the procedural steps:
Post-procedure care following an incisional biopsy of the eyelid skin is important for ensuring proper healing and monitoring for any complications. Patients are typically advised to keep the biopsy site clean and dry, and to follow any specific instructions provided by the healthcare provider regarding wound care. It is common for patients to experience some swelling, bruising, or discomfort in the area, which can usually be managed with over-the-counter pain relief medications. Follow-up appointments may be scheduled to assess the healing process and to discuss the results of the histological evaluation. Patients should be informed to report any signs of infection, such as increased redness, swelling, or discharge from the incision site, to their healthcare provider promptly.
| Short Descr | INCAL BX EYELID SKN LID MRGN | Medium Descr | INCISIONAL BIOPSY EYELID SKIN W/LID MARGIN | Long Descr | Incisional biopsy of eyelid skin including lid margin | Status Code | Active Code | Global Days | 000 - Endoscopic or 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 MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 18 - Diagnostic procedures on eye |
| E2 | Lower left, eyelid | E4 | Lower right, eyelid | 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. | E3 | Upper right, eyelid | 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) | 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). | 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.) | 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. | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 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. | 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.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | ET | Emergency services | F3 | Left hand, fourth digit | 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 | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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 | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | SG | Ambulatory surgical center (asc) facility service | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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 and Medium Descriptions changed. |
| 2013-01-01 | Changed | Description changed. Guideline information changed. |
| Pre-1990 | Added | Code added. |