Ophthalmology and Optometry Coding Alert

Make sure your medical necessity and surgical approach documentation is ironclad to prevent claims misfires -- here's how.

Blepharoptosis repair procedures can bring a lot of revenue into your practice, but coding them can be fraught with danger. Payers are looking for reasons to deny your claim, in the absence of evidence that the ophthalmic surgeon performed the procedure for medical, not cosmetic, reasons. And you may need to study the op note carefully before you can tell just which oculoplastic procedure your surgeon performed. We've outlined the keys for determining the correct CPT® codes for the top-six oculoplastic procedures below.

To correctly code oculoplastic surgery on eyelids, you need detailed information about the surgical techniques the ophthalmologist used, as well as the specific anatomic sites involved. Getting a single detail wrong could prove costly to your practice.

Many of the blepharoptosis repair codes (67901-67908, Repair of blepharoptosis ...) describe procedures that seem almost identical. There are key differences, however, that will help you choose the correct code for the procedure your ophthalmologist performed, experts say.

Beware: Adding to the difficulty is the fact that Medicare often questions the medical necessity of oculoplastic procedures, especially blepharoptosis repair, experts say. Codes 67901-67911 represent procedures that physicians may also perform strictly for cosmetic purposes, and because of this Medicare may question whether to cover these procedures. Be sure your documentation includes relevant medical history, visual field test results, external photographs, and physical examination records. Check with your local carrier for any additional specific requirements when providing oculoplastic services, advises Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital Ambulatory and Network Oversight at the Mount Sinai Medical Center Compliance Department in New York City.

Procedure 1: Frontalis Fixation

AKA: Frontalis suspension, frontalis sling

Code: 67901 (... frontalis muscle technique with suture or other material [e.g., banked fascia])

Look for: The key to this procedure is the phrase suture or other material in the code description. In this procedure, the ophthalmologist passes a needle equipped with threadlike material through incisions in the brow and eyelid, creating a sling to support the drooping eyelid. Possible suture materials include preserved and autogenous fascia lata, #40 silicone bands, silicone rods, and prolene sutures.

This is also the highest-valued of the 67901-67908 codes. The Physician Fee Schedule assigns 67901 21.86 RVUs; multiplied by the 34.0376 conversion factor, this leads to $744.06 in reimbursement before applying geographic adjustments.

Procedure 2: Frontalis Fixation With Fascial Sling

AKA: Frontalis suspension

Code: 67902 (... frontalis muscle technique with fascial sling [includes obtaining fascia])

Look for: This procedure is almost exactly the same as that for code 67901. The difference? The ophthalmologist uses a sling of fascia lata -- thin fibrous tissue from the thigh -- to suspend the drooping eyelid. He may also use irradiated fascia taken from cadavers. Only use 67902 if you confirm that the ophthalmologist used fascia lata tissue.

Don't miss: The description for 67902 states, "includes obtaining fascia." You shouldn't have a separate code -- for example, from the 20000 section of the CPT® code book -- for the harvesting of the fascia, which is included in the description and payment of the procedure, says Mac.

Procedure 3: Levator Resection, Internal Approach

AKA: Tarsolevator resection, tarsolevator advancement

Code: 67903 (... [tarso] levator resection or advancement, internal approach)

Look for: The approach is the key for 67903. To report 67903, you have to have documentation that the eyelid was turned inside out, and the surgical approach was literally from the conjunctival side. The ophthalmologist accesses the levator aponeurosis (a fanlike extension of the levator muscle) through the conjunctiva, and either resects or advances the tissue to correct the drooping.

Procedure 4: Levator Resection, External Approach

AKA: Tarsolevator resection, tarsolevator advancement

Code: 67904 (... [tarso] levator resection or advancement, external approach)

Look for: As with 67903, the approach is the key for 67904. In this case, the ophthalmologist resects or advances the levator through an incision into the eyelid fold.

Hidden trap: Be careful -- because this may be the approach that you see most often, you don't want to inappropriately assign this code in the rare chance that it's actually an internal approach procedure.

Procedure 5: Superior Rectus Sling

Code: 67906 (... superior rectus technique with fascial sling [includes obtaining fascia])

Look for: The ophthalmologist uses the superior rectus muscle, which is attached to the outside of the eyeball, to suspend the drooping eyelid. Note that like 67902, the description for this code tells you that obtaining the fascia is included -- do not code separately for that.

However: Don't expect to see too many of these. This procedure runs the risk of reducing the function of the superior rectus muscle, so ophthalmologists do not perform it often.

Procedure 6: Fasanella Procedure

AKA: Conjunctivo-tarso-Muller's muscle-levator resection, internal tarsoconjunctival Mullerectomy

Code: 67908 (... conjunctivo-tarso-Muller's muscle-levator resection [e.g., Fasanella-Servat type])

Look for: As he does in 67903, the ophthalmologist performing 67908 turns the eyelid inside out. There will usually be some reference to a clamp in the operative note, since the procedure involves clamping the superior tarsal border. The operative notes may also refer to the removal of the tarsus, conjunctiva, levator aponeurosis and Muller's muscle all at once.