Ophthalmology and Optometry Coding Alert

Look to the blepharoptosis repair codes when the fix involves muscle modification.

Two of the main non-ocular culprits of visual impairment are excess skin that hangs over the edge of the eyelid and a lower-than-normal position of the eyelid relative to the pupil. While the eyelid procedures performed to correct the underlying problem are relatively straightforward, the coding for these surgeries can be so tricky that even the most experienced coders have questions about clean claims and reimbursement. Keep reading for five pro tips that will help you land on the correct code every time.

Tip 1: Learn the Lingo

When your provider discovers reduced visual fields due to eyelid obstruction, they may decide surgical reconstruction is needed to rectify the issue. Drooping eyelids may be caused by the loose and redundant skin of the upper eyelids with aging (dermatochalasis) or by the weakening of the muscles (eyelid ptosis) responsible for opening your eyes.

When excess skin is the problem, the solution is blepharoplasty, which involves the surgical removal of excess skin and fat from the upper (or lower) eyelids, This may be done to improve abnormal function, reconstruct deformities, or enhance appearance. An upper blepharoplasty addresses the drooping eyelid skin by removing the excess tissue affecting vision.

Ptosis of the upper eyelid, or blepharoptosis, results from weakening or separation of the muscles that are responsible for opening the eyelids, and surgery to repair the drooping upper eyelid involves a shortening or tightening of the stretched muscle.

Tip 2: Understand How 15820-15823 and 67901-67908 Differ

When the physician excises skin and fat, you’ll turn to the blepharoplasty codes (15820-15823). If the surgery involves revision of the actual muscle, you’ll select from the ptosis repair codes 67901-67908 (Repair of blepharoptosis ...). For example, 67904 (... [tarso] levator resection or advancement, external approach), in which the surgeon shortens the levator tendon until the lid is at the proper level, correcting the ptosis.

Both code sets address the same problem — reduced fields of vision due to eyelid obstruction. However, they represent two different solutions to address the two different etiologies.

“Not infrequently, a medically necessary ptosis repair and a medically necessary blepharoplasty are performed on the same eye, in the same operative session,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group. But “National Correct Coding Initiative (NCCI) edits bundle these codes,” so you’ll need to break the bundle using the appropriate modifier.

Tip 3: Know Which Modifiers Might Be Needed

Blepharoplasty codes 15820-15821 (Blepharoplasty, lower eyelid …) and 15822-15823 (Blepharoplasty, upper eyelid …) all specify upper or lower eyelid. Therefore, you should only need to specify the side — right or left — that your surgeon fixed. To do so, you’ll add modifier LT (Left side) or RT (Right side) to the blepharoplasty code. For example, 15822- LT specifically indicates blepharoplasty performed on the upper left eyelid.

Take note: There may be different policies among your individual insurers on proper how to use modifiers to report the procedure. Some may want you to use an eyelid modifier, such as E1 (Upper left, eyelid) or E3 (Upper right, eyelid), with the blepharoplasty code.

Example: A payer may require you to report blepharoplasty on the upper left eyelid with 15822-E1. If the ophthalmic surgeon performs blepharoplasty on both upper eyelids, you may need to append modifier 50 (Bilateral procedure) instead. “Medicare, for example, assigns a medically unlikely edit of “1” to code 15823, which requires billers to report bilateral procedures as 1 unit using modifier 50,” Johnson adds.

The descriptions for 67901-67908 do not specifically mention upper or lower eyelids. But blepharoptosis is defined as “drooping of the upper eyelids,” so your ophthalmologist would perform a blepharoptosis repair procedure only on the patient’s upper eyelids. Again, some payers accept modifiers LT or RT, whereas others want you to use E1-E4.

Tip 4: Determine if Blepharoplasty Is Reconstructive or Cosmetic

Your answer will depend on the procedure and the patient’s main complaint. Procedures to remove excess skin and fat from the eyelids are often medically necessary — but to support medical necessity and convince insurers, you need to submit the correct codes and airtight documentation.

Insurers cover blepharoplasty procedures 15822 (Blepharoplasty, upper eyelid) and 15823 (… with excessive skin weighting down lid) when the patient suffers from decreased vision or other specific medical problems.

Look out: CPT^® codes 15820 and 15821 (… with extensive herniated fat pad) are rarely covered. Insurers believe that excessive skin or fat in the lower eyelids does not usually obscure vision and its removal is typically for cosmetic reasons, with a few exceptions.

Tip 5: Check for VF Testing and Photos

Most payers require documentation that shows an improvement in the superior visual field that will result from the surgery. The ophthalmologist does visual field (VF) testing in two steps: first, in the normal fashion and then with the eyelids taped to pull the drooping tissue out of the way of the patient’s eyes, simulating surgical results, says Maggie M. Mac, CPC, CEMC, CDEO, AAPC Fellow, CHC, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida. The test is meant to show that vision will improve if the eyelid problem is solved — with tape temporarily, with surgery more permanently.

Heads up: Many insurer policies require a 12 to 30 percent improvement between the two VF tests. They may have specific photographic requirements, as well. For example, Medicare’s local coverage article (A52837) says that “photographs for the purpose of justifying an eyelid procedure(s) and/or brow ptosis procedures due to superior visual field loss must demonstrate that the upper eyelid margin approaches to within 2.5 mm of the corneal light reflex.” In other words, the margin reflex distance (MRD) has to be 2.5 mm or less. The article goes on to list additional specific photographic requirements for the various procedures.

Billing: Because your ophthalmologist performs the VF testing twice, you may be tempted to code the service twice. Unfortunately, with some payers, you can bill only once for the VF test using CPT^® code 92081 (Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent)) to show the work of a single isopter test performed twice. Code 92081 is only “reported once regardless of whether the examination is performed more than once, unilaterally or bilaterally,” according to CPT^® Assistant (Sept. 2010).

Other payers suggest reporting 92082 (Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination …), but this requires testing at an intermediate level — for example, at least two isopters on a Goldmann perimeter. “To show an improvement in the superior field, the same stimulus (size and intensity) is required for both the taped and the untapped visual field,” Johnson notes.

Alternative: Some payers will reimburse you for both tests because they mandate two VF tests, which require extra work by the ophthalmologist. In this case, you should append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to the second test and thus report 92082 and 92082-76. You can add comments in Block 19 of the claim form to indicate “taped and untaped.”

Best bet: Verify with each payer how you should code for visual field testing prior to eyelid surgery.