Ophthalmology and Optometry Coding Alert

We talk to many office managers and billers for ophthalmology practices who give up too soon when a claim is denied. They dont want to go through the hassle of an appeal. But they often arent sure of exactly what an appeal would entail. Well, it entails a lot of waiting, but not a lot of time or effort, according to an ophthalmology practice which recently won an appeal that took two years to complete. The practice agreed to talk to us about the process because it believes that if more ophthalmologists appealed denials, such denials would be less routine and more carefully considered by carriers.

The appeal was for procedures which are often denied: 67904 (repair of blepharoptosis; [tarso]levator resection or advancement, external approach) and 15823 (blepharoplasty, upper eyelid; with excessive skin weighting down lid). The ophthalmologist who performed the procedures insisted that they were done for medical necessity, and made it a matter of principle to get Medicare to agree. And, eventually, Medicare did.

But the ophthalmologist had to wait for the right person to whom he could make these arguments. Heres how it happened, with an explanation of what led to the denials, and the process for ultimately winning payment.

1.The first mistake: not doing the external photos or visual fields before surgery. You need to prove to Medicare that these procedures are not for cosmetic purposes. When the first denial came in from Medicare for 67904 and 15823, Michelle Risk, insurance specialist for Thornapple Ophthalmology, a solo practice in Hastings, MI, resubmitted the claim. The original claim had not included external photos (92285) or visual fields (92081-92083) which were not done prior to surgery. Risk says both types of photos and visual fields are required by her Medicare carrier for payment of 67904 and 15823even done separately. Also in this case, both procedures were done bilaterally, and both procedures were done at the same time, so she filed using modifier -50 (bilateral procedure).

Risk thought that it was because of the omission of the external photos and the visual fields that the claim was denied. Blepharoplasty and ptosis repair claims are scrutinized by Medicare for medical necessity, and three thingsexternal photos, visual fields, and the operative noteare essential to get these paid, says Risk. She did send the operative noteand she filed paper claims. Anything that could be cosmetic needs these, she explains. Thats why I sent this on paper. You need to document that the repair is not being done for cosmetic purposes so the photos and visual fields have to show the procedures were medically necessary due to the eyelids drooping down over the field of vision. Thus, when Risk resubmitted the claim, [...]