Ophthalmology and Optometry Coding Alert

Tip: Make sure you know your carrier's preference on E1-E4 vs. LT-RT 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. Hang on to VF Documentation and Photos 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 [...]