Ophthalmology and Optometry Coding Alert

Are you missing out on deserved reimbursement for 15820-15823?

Many ophthalmologists are not claiming legitimate reimbursement for medically necessary blepharoplasty.

Most insurers, including Medicare carriers, are predisposed to denying payment, and to assuming the procedure is cosmetic. However, armed with our expert advice, you’ll be well on the road to successful claims.

Blepharoplasty Procedures Are Not Always Cosmetic

Whether or not a blepharoplasty procedure is cosmetic depends on the procedure and the patient’s main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done due to medical necessity — but to support medical necessity and convince Medicare, you need to submit the correct codes and airtight documentation, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

For blepharoplasty procedures, look to CPT^® codes 15820-15823 (Blepharoplasty …). Insurers cover blepharoplasty procedures 15822 (Blepharoplasty, upper eyelid) or 15823 (… with excessive skin weighting down lid) when the patient suffers from decreased vision or other specific medical problems.

For example, Medicare carrier Palmetto’s local coverage determination (LCD) states that they will cover blepharoplasty as functional or reconstructive surgery to correct:

·         documented ptosis, pseudoptosis, or dermatochalasis

·         interference with vision or visual field

·         difficulty reading due to upper eyelid drooping

·         the patient looking through the eyelashes or seeing the upper eyelid skin

·         chronic blepharitis

·         visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis

·         symptomatic redundant skin weighing down on upper lashes

·         chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin

·         prosthesis difficulties in an anophthalmic socket.

But: CPT^® codes 15820 (Blepharoplasty, lower eyelid) and 15821 (… with extensive herniated fat pad) are almost never covered. Insurers believe that excessive skin or fat in the lower eyelids do not usually obscure vision.

Keep Everything Documented

With many providers and insurers moving toward electronic claims, submitting extensive documentation just isn’t always possible. You should, however, keep everything documented on file in the patient’s medical record. You can send a paper claim with the documentation after you file electronically, with a statement on the paper claim saying that it is a documentation copy, not a duplicate copy. After the carrier receives the claim, it may ask for additional documentation by sending you an additional document request (ADR) letter.

Keep this documentation in your blepharoplasty patient’s file:

·         history and physical which documents the patient’s complaint extensively to support problems with performing activities of daily living (e.g., driving, reading, chronic eye irritation, etc.)

·         operative report

·         visual fields (taped and untaped)

·         photographs (taped and untaped).

The visual field (VF) tests (92081-92083, Visual field examination, unilateral or bilateral, with interpretation and report ...) show the extent of the patient’s decreased vision. Most carriers want two sets of visual fields — one with the upper eyelid at rest and one with the eyelid taped up to demonstrate an expected improvement. Be sure to document both sets of results with the physician’s interpretation and report. Many LCDs state that the visual fields “must demonstrate a minimum 12 degrees or 30 percent loss of upper field of vision.”

For photographs, carriers usually want prints — not slides — showing one or more of these conditions:

·         The upper eyelid margin approaches to within 2.5 mm (one-fourth of the diameter of the visible iris) of the corneal light reflex.

·         The upper eyelid skin rests on the eyelashes.

·         The upper eyelid indicates the presence of dermatitis.

·         The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.

“When photographs, slides or videos are taken, they must be frontal, canthus-to-canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudolid margin,” directs Medicare carrier TrailBlazer’s blepharoplasty LCD. “The photographs, slides or videos must be of sufficient clarity to show a light reflex on the cornea.”

Know the Difference Between 67901-67908 and 15820-15823?

Two different code sets address the same problem — reduced fields of vision due to eyelid obstruction. However, they represent two different underlying causes and two different solutions to the problem.

Blepharoplasty (15820-15823) is a removal of excessive skin or subcutaneous fat. The repair codes 67901-67908 (Repair of blepharoptosis ...) represent a revision in the actual muscle — for example, 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach), in which the ophthalmologist shortens the levator tendon until the lid is at the proper level.

Watch for Bilateral Nuances

The idea that blepharoplasty is inherently bilateral can be an especially costly misperception. CPT^® codes 15822 and 15823 are inherently unilateral, meaning that the ophthalmologist will not necessarily perform the procedure on both upper eyelids at once.

If the ophthalmologist performs blepharoplasty on both upper eyelids, report 15822 or 15823 with modifier 50 (Bilateral procedure) appended. Modifier 50 usually tells the carrier to apply a 150 percent payment adjustment to the claim. Some payers may prefer you to  report the procedure on two lines with modifiers LT (Left side) and RT (Right side).

Example: In the office, the ophthalmologist removes excess skin weighing down both upper eyelids. You report 15823-50. The carrier multiplies the nonfacility RVUs for 15823 by 1.5 (18.80 RVUs in 2013 x 1.5 = 28.20).

Multiplying that by the 2013 conversion factor (34.023) yields $959.45 before any geographic adjustment, earning you $319.82 more than if you had reported the procedure unilaterally (18.80 x 34.023 = $639.63).

If the ophthalmologist only performed blepharoplasty on one eye, report 1582x on one line with modifier LT or RT appended to indicate which eye he operated on.