Summary & Overview
CPT 67974: Full-Thickness Upper Eyelid Reconstruction with Eyelid Flap
CPT code 67974 represents full-thickness reconstruction of the upper eyelid with transfer of a tissue flap from the opposing eyelid. This complex oculoplastic procedure restores eyelid structure and function after trauma, tumor resection, or congenital defects, and can be staged across multiple sessions. Nationally, accurate coding for extensive eyelid reconstruction is important for appropriate payment, clinical documentation, and care coordination among surgical teams.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. Readers will find a concise overview of the clinical intent of the code, expected site of service and service type, and the payer landscape addressed in this publication. The analysis highlights typical billing contexts, common modifiers listed for procedural circumstances, and relevant clinical considerations for coding and documentation.
This publication provides benchmarks and policy context relevant to the code, outlines documentation elements that support medical necessity claims for extensive eyelid reconstruction, and summarizes variations in payer handling where available. Data not provided in the input are noted explicitly. The goal is to equip coding, billing, and clinical staff with a clear, national-level reference for CPT code 67974.
Billing Code Overview
CPT code 67974 describes reconstruction of the entire surface area of an upper eyelid, extending through all tissue layers, with transfer of a tissue flap from the opposing eyelid. The procedure is intended to correct eyelid damage and to improve both cosmetic appearance and eyelid function. The reconstruction may be performed in staged sessions when clinically necessary.
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Service type: Full-thickness upper eyelid reconstruction with eyelid flap transfer (surgical reconstructive procedure)
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Typical site of service: Hospital operating room or ambulatory surgical center, often performed by oculoplastic or reconstructive surgeons under operative conditions
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Clinical & Coding Specifications
Clinical Context
A 72-year-old male presents to oculoplastic surgery clinic after Mohs micrographic surgery for a basal cell carcinoma that involved the full thickness of the right upper eyelid and lateral canthus. The defect extends through skin, tarsus, and conjunctiva, resulting in an eyelid margin deficit with exposure of the globe and impaired eyelid closure. The surgeon plans a staged reconstructive procedure using a tarsoconjunctival flap (Hughes-like or Cutler-Beard type approach) transferred from the opposing eyelid to reconstruct the entire upper eyelid margin and posterior lamella, with anterior lamellar repair and possible cartilage grafting for support.
Preoperative workflow includes history and physical, informed consent documenting full-thickness upper eyelid defect and functional indication (protection of the cornea, restoration of eyelid closure), photographic documentation, and coordination for staged surgery. The procedure is typically performed in an ambulatory surgery center or hospital outpatient setting under local with sedation or general anesthesia, with postoperative follow-up for flap viability, suture removal, and potential second-stage division of the flap several weeks later to restore independent eyelid movement.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when substantial additional work beyond typical is required (extensive dissection, multiple ancillary grafts) and documentation supports increased effort. |