Ophthalmology and Optometry Coding Alert

What you don't know can hurt you -- to the tune of $294 per procedure.

Don't assume all eyelid procedures are cosmetic. You could be cheating your practice out of insurance reimbursement if the surgery is medically necessary.

Ophthalmic surgeons who perform blepharoplasty know that most insurers, including Medicare carriers, are predisposed to denying payment, and to assuming the procedure is cosmetic. While that's true, be aware of four myths that are preventing ophthalmologists from claiming legitimate reimbursement for medically necessary blepharoplasty.

Reality: It depends on the procedure and the patient's main complaint.Procedures to remove excess skin and fat from the eyelids are frequently done out of medical necessity -- but to convince Medicare, you need the right codes and airtight documentation.

For blepharoplasty procedures, look to CPT codes 15820-15823 (Blepharoplasty ...), says Becky Zellmer, CPC-E/M, MBS, CBCS, COTA, provider educator for Prevea Clinic in Green Bay, Wis., who led the "Oculoplastics Coding" seminar at The Coding Institute's Ophthalmology & Optometry 2009 Coding Update and Reimbursement Conference in December.

Insurers cover blepharoplasty procedures 15822 (Blepharoplasty, upper eyelid) or 15823 (... with excessive skin weighting down lid) when the patient suffers from decreased vision or other specific medical problems. For example, Medicare carrier Palmetto's local coverage determination (LCD) states that they will cover blepharoplasty as functional or reconstructive surgery to correct:

• documented ptosis, pseudoptosis, or dermatochalasis

• interference with vision or visual field

• difficulty reading due to upper eyelid drooping

• the patient looking through the eyelashes or seeing the upper eyelid skin

• chronic blepharitis

• visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis

• symptomatic redundant skin weighing down on upper lashes

• chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin

• prosthesis difficulties in an anophthalmic socket.

(For specific ICD-9 codes to back up medical necessity, see "Show Medical Necessity for Blepharoplasty: Here's How" on page 11.)

But: CPT codes 15820 (Blepharoplasty, lower eyelid) and 15821 (... with extensive herniated fat pad) are almost never covered, says Zellmer. Insurers believe that excessive skin or fat in the lower eyelids do not usually obscure vision.

Reality: With many providers and insurers moving toward electronic claims, submitting extensive documentation just isn't always possible. You should, however, keep everything on file in the patient's medical record. You can send a paper claim with the documentation after you file electronically, with a statement on the paper claim saying that it is a "documentation copy, not a duplicate copy," says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. After the carrier receives the claim, it may ask for additional documentation by sending you an additional document request (ADR) letter.

Keep this documentation in your blepharoplasty patient's file:

• history and physical

• operative report

• visual fields

• photographs.

The visual field (VF) tests (92081-92083, Visual field examination, unilateral or bilateral, with interpretation and report ...) show the extent of the patient's decreased vision. Most carriers want two sets of visual fields -- one with the upper eyelid at rest and one with the eyelid taped up to demonstrate an expected improvement. Be sure to document both sets of results. The visual fields "must demonstrate a minimum 12 degrees or 30 percent loss of upper field of vision," says Palmetto's LCD.

For photographs, carriers usually want prints -- not slides -- showing one or more of these conditions:

• The upper eyelid margin approaches to within 2.5 mm (one-fourth of the diameter of the visible iris) 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 anophthalmia socket.

"When photographs, slides or videos are taken, they must be frontal, canthus-to-canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudolid margin," directs Medicare carrier TrailBlazer's blepharoplasty LCD. "The photographs, slides or videos must be of sufficient clarity to show a light reflex on the cornea."

Reality: Both code sets address the same problem -- reduced fields of vision due to eyelid obstruction. However, they represent two different underlying causes and two different solutions to the problem.

Blepharoplasty (15820-15823) is a removal of excessive skin or subcutaneous fat, explains Zellmer. The repair codes 67901-67908 (Repair of blepharoptosis ...) 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.

Reality: This can be an especially costly misperception. CPT codes 15822 and 15823 are inherently unilateral, meaning that the ophthalmologist will not necessarily perform the procedure on both upper eyelids at once.

If the ophthalmologist performs blepharoplasty on both upper eyelids, report 15822 or 15823 with modifier 50 (Bilateral procedure) appended, Zellmer says. Modifier 50 usually tells the carrier to apply a 150 percent payment adjustment to the claim. Another option is to report the procedure on two lines with modifiers LT (Left side) and RT (Right side), she says.

Example: In the office, the ophthalmologist removes excess skin weighing down both upper eyelids. You report 15823-50. The carrier multiplies the nonfacility RVUs for 15823 by 1.5 (16.28 RVUs in 2009 x 1.5 = 24.42).

Multiplying that by the 2009 conversion factor (36.0666) yields $880.75 before any geographic adjustment, earning you $293.59 more than if you had reported the procedure unilaterally (16.28 x 36.0666 = $587.16).

If the ophthalmologist only performed blepharoplasty on one eye, report 1582x on one line with modifier LT or RT appended to indicate which eye he operated on.