Blepharophimosis left upper eyelid

This code describes a congenital or acquired condition characterized by a reduced vertical and horizontal opening of the left upper eyelid. It often involves ptosis, epicanthus inversus, and telecanthus, leading to a narrowed palpebral fissure.

Apply this code when documentation specifies blepharophimosis affecting the left upper eyelid. This diagnosis is typically made based on clinical examination noting the characteristic eyelid malformation. Supporting documentation includes ophthalmology notes detailing the specific eyelid involvement.

• Ensure laterality is clearly documented as "left upper eyelid" to support this specific code.
• Distinguish from general ptosis (H02.4x) or other eyelid malpositions if blepharophimosis is not explicitly stated.
• Consider co-occurring conditions like epicanthus inversus or telecanthus, which may require additional codes.