AHA Coding Clinic® for HCPCS - 2025 Issue 1; Ask the Editor

Sub-orbicularis oculi fat lift with ectropion repair

A patient presented for bilateral ectropion repair, requiring a bilateral rotational flap with sub-orbicularis oculi fat lift (SOOF). A transconjunctival incision was made below the inferior border of the tarsus and dissection was carried out in the pre-septal plane down to the orbital rim. The orbitomalar ligament was incised. A myocutaneous flap was lifted by dissecting the surrounding tissue in the pre-periosteal plane extending down to the pyriform fossa inferiorly and the mandible laterally. A SOOF was performed to further raise the lower lid and cheek. The myocutaneous flap was advanced superiorly and secured to the periosteum of the orbital rim. Attention was then turned to harvesting the hard palate graft. An incision was made through the mucosa of the hard palate to the underlying fat layer. The incision was carried from the junction of the hard and soft palate posteriorly to the rugae anteriorly. The blade was used to harvest the palate at the layer of the visible fat. The palate graft was then trimmed and sutured to the inferior border of the tarsus medially to laterally. The graft was then covered by conjunctiva and the lateral canthus was re-attached to the orbital rim and the canthal angle was reformed. The same procedure was performed on the other side.Should the SOOF procedure be reported in addition to the ectropion repair? If it is separately reported which CPT code should be assigned? ...

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