Ophthalmology and Optometry Coding Alert

Editors note: In this article, we focus on Florida, where the Medicare carrier does not bundle these two procedures.

Coding for blepharoplasty (15820-15823) and levator repair (67904) can be tricky. You need to make sure the procedures are being done for medically necessary purposessuch as excess skin and fat impeding vision. Always check with your carrier to make sure there is a Local Medicare Review Policy (LMRP) regarding these two procedures, since they are similar.

Sometimes a patient needs blepharoplasty, which involves excision of skin and fat, and levator repair, which involves muscle. Coders can get confused when both procedures are done at the same time because it may seem that the skin and fat are included in the muscle procedure. However, they may not be, depending on where in the country the practice resides. For example, in Florida these two procedures are not bundled, says Marie Stamper, CMM, office manager of Ward Eye Center in Homosassa, Fla.

The Florida Medicare carrier has an LMRP that guides practitioners and claims processors on criteria for payment. In simple terms the policy states that blepharoptosis repair does not include blepharoplasty, but that blepharoplasty may be either medically necessary or cosmetic. The policy gives information on external photos and visual fields that should be done to demonstrate that both the weak levator muscle and excess skin weighting the eyelid down are causes for impaired vision. If the blepharoplasty is cosmetic, the patient is responsible for payment, but it is not included in the blepharoptosis repair. A few other states have established similar LMRPs. Check with your Medicare carrier to find out if an LMRP for these services exists in your area.

In Florida, you would bill first for the levator resection, since this is the higher-paying procedure. If done externally, use 67904 (repair of blepharoptosis; [tarso] levator resection or advancement, external approach). You should use modifier -50 (bilateral procedure) if the procedure is done bilaterally, and double your price, says Stamper.

Second, for the blepharoplasty, you need to code whether the upper or lower lid is being done, and also indicate whether excess tissue is involved. You would bill either 15822 (blepharoplasty, upper eyelid), which is considered cosmetic, or 15823 (blepharoplasty, upper eyelid; with excessive skin weighting down lid), which is covered with appropriate documentation of medical necessity. If the blepharoplasty is on the lower lid, bill 15280 (blepharoplasty, lower eyelid), or in the case of excess fat, 15821 (blepharoplasty, lower eyelid; with extensive herniated fat pad). Both of these codes are considered cosmetic procedures. Neither code is a bilateral code, so you should append modifier -50 to whichever blepharoplasty code you use if you perform the procedure bilaterally, and you should also double your fee, says Stamper.

Then, to indicate multiple procedures, you should append modifier -51 (multiple procedures) to the blepharoplasty. This means you could have 67904-50 on the first line, and 15822-50-51 on the second line, if both procedures are bilateral.

The rules of billing say you should always put the higher-paying procedure on the first line, explains Stamper. This is because with multiple procedures, Medicare pays you 100 percent of the top procedure, and 50 percent of the second. If you make a mistake, Medicare will often move the procedures around on the form so you do get the maximum reimbursement, says Stamper. But not always. So to cover yourself, make sure you have the highest-paying procedure first.