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.Myth #1: Blepharoplasty Procedures Are Always CosmeticReality: 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.Myth #2: All Documentation Must Be Submitted Along With the Original ClaimReality: 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 [...]