Ophthalmology and Optometry Coding Alert

Your ophthalmologist doesn't use blepharoplasty and ptosis repair just for cosmetic reasons, and you can't let your payers believe this either. Let these expert tips guide you through coding your ophthalmologist's repair procedures.

Coding blepharoplasty and ptosis repair can get complicated if you don't meet requirements like keeping visual field data in the patient's records and proving medical necessity. You-ll also have to be sure you-re appending the proper modifiers for the procedures if you want to see proper reimbursement.

Many payers assume that your ophthalmologist performs blepharoplasty for cosmetic reasons, and therefore the payer may not consider the procedure medically necessary and deny your claim. Don't lose hope, though. If your physician documents that the ptosis (drooping eyelids) is impairing the patient's vision, you should get paid.

The ophthalmologist does the visual fields (VF) test twice, says Douglas Anderson, MD, professor of ophthalmology at Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine. The ophthalmologist performs the VF once normally and once with the eyelids taped to pull the drooping tissue out of the way of the patient's eyes and to simulate surgery results.

"The test is meant to show that vision will improve if the eyelid problem is solved -- with tape temporarily, with surgery more permanently," Anderson says.

Tip: Many carrier local medical review policies (LMRPs) require a 12 to 30 percent improvement between the two VF tests. They may also have specific criteria that the photos must show. For example, the LMRP for Wheatlands Administrative Services, a subsidiary of Blue Cross and Blue Shield of Kansas and the Medicare carrier covering Kansas, Nebraska and Northwest Missouri, says the photos need to demonstrate "one or more" of the following:

- the upper eyelid margin approaches to within 2.5 mm (one-quarter of the visible iris- diameter) 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 anophthalmic socket.

How it works: You should have documentation of the VF tests and photos on file in case you ever face an audit of your blepharoplasty claims. Carriers will initially look at the diagnosis code you submit on the claim form to make sure it establishes medical necessity. The carrier may then request documentation prior to payment for some or all cases. The VF tests help prove medical necessity, says Brenda Brooks, reimbursement specialist/coding for the department of ophthalmology at UT Medical Group in Germantown, Tenn.

Bonus: For a list of ICD-9 codes that commonly support medical necessity for blepharoplasty and brow repair, see "Prove Blepharoplasty Wasn't Just Cosmetic With These 14 Dx Codes" on page 63.

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. You should use 92082 (Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination [e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33]) to show the work of drawing two isopters (the graphic representation of the patient's field of vision).

Alternative: Some carriers will reimburse you for both tests because they mandate two VF tests, which requires extra work by the ophthalmologist. In this case, you should append modifier 76 (Repeat procedure by same physician) to the second test and report 92082 and 92082-76. You can add comments in Block 19 of the claim form to indicate "taped and untaped."

Best bet: Ask your local carrier how you should code these two tests.

When your ophthalmologist is treating a patient's reduced fields of vision due to eyelid obstruction, you have two code sets to look at: 67901-67908 and 15820-15823. So which should you choose? To choose the right code, look at the underlying causes. The two code sets represent two different underlying causes and two different solutions to the problem.

Blepharoplasty -- represented by 15820-15823 -- is an excision of skin and fat. The repair codes 67901-67908 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. You would code a ptosis repair from the 67901-67908 series, Brooks says.

Caution: Since 2000, the Correct Coding Initiative (CCI) has bundled 15820 (Blepharoplasty, lower eyelid) and 15822 (Blepharoplasty, upper eyelid) into blepharoptosis repair codes 67901 (Repair of blepharoptosis; frontalis muscle technique with suture or other material), 67902 (... frontalis muscle technique with autologous fascial sling), 67903 (... [tarso] levator resection or advancement, internal approach), 67904, 67906 (... superior rectus technique with fascial sling) and 67908 (... conjunctivo-tarso-Muller's muscle-levator resection).

Result: If your ophthalmologist performs both blepharoplasty and blepharoptosis repair during the same session, you can break the bundle, when appropriate, by appending modifier 59 (Distinct procedural service) to the blepharoplasty procedure.

Blepharoplasty codes 15820-15821 (Blepharoplasty, lower eyelid -) and 15822-15823 (Blepharoplasty, upper eyelid -) all specify an upper or lower eyelid. Therefore, you should only need to specify the particular eyelid -- right or left -- that your ophthalmologist fixed. To do so, you-ll add modifier LT (Left side) or RT (Right side) to the blepharoplasty procedure code. For example, 15822-LT could only describe blepharoplasty performed on the upper left eyelid.

Alternative: Again, there may be different policies among your individual carriers on how to use modifiers to report the procedure. Some carriers may want you to use an eyelid modifier with the blepharoplasty code.

Example: A carrier may require you to report blepharoplasty on the upper left eyelid with 15822-E1. If the ophthalmologist performs blepharoplasty on both upper eyelids, you may also need to append modifier 50 (Bilateral procedure).

Remember: The descriptions for 67901-67908 (Repair of blepharoptosis -) 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 carriers accept modifiers LT or RT, whereas others want you to use E1-E4.