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AHA Coding Clinic® for HCPCS - 2022 Issue 2; Ask the Editor

Bilateral midface lift with bilateral canthoplasty

A patient status post canthoplasty presented with facial asymmetry and issues with the positioning of her eyelids secondary to facial nerve paralysis. A bilateral midface lift and bilateral canthoplasty were performed to correct the ectropion and facial ptosis. Both lateral canthus areas were anesthetized and a cantholysis and canthotomy were performed. The infraorbital area was accessed through the canthotomy and the midface area was accessed through the lateral crow’s feet incision. The midface lift was performed through the lateral incision into the crow’s feet by elevating soft tissue above the periosteum. To gain mobility, the connections of the masseter muscle to the midface soft tissue and scar bands from a previous surgery were severed. Due to thickened tissue and scarring, anchors and sutures were utilized in the lateral canthal area to suspend the midface and thus supporting the lower eyelid and correcting the ectropion. After the muscle and skin layers were closed, the suspensory ligament was repositioned into the lateral canthal periosteum. The skin of the canthoplasty was closed with sutures. This procedure was performed on the right and left sides.What CPT code(s) are assigned to capture a midface lift performed to correct ectropion and facial ptosis when canthoplasty incisions are utilized to gain access to the midface? ...

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