Ophthalmology and Optometry Coding Alert

Ophthalmologists cannot get reimbursed by Medicare when they perform blepharoplasty on the lower eyelid for cosmetic reasons, such as removing bags under the eyes (15820-15821). But they can be reimbursed if the blepharoplasty is medically necessary, such as for repair of entropion or ectropion (374.1x), by using the eyelid repair codes (67914-67924). Entropion (lower-lid lash line turns toward the eyeball) and ectropion (lower lid droops and turns away from the eyeball) can damage the eye and must be repaired surgically.

Lise Roberts, vice president of Health Care Compliance Strategies, a coding and compliance consultant based in Jericho, N.Y., says, Most ophthalmologists know to stay away from the blepharoplasty codes [15820-15821]. Theyve experienced payment problems with them, and the entropion and ectropian repair codes describe the surgical procedure more accurately. Medicare will never pay for 15820 or 15821, says Deborah Rogers, COT, clinic manager for Andersen Eye Associates of Saginaw, Mich. These codes are strictly for cosmetic surgery, such as removing droopy skin or bags under the eyes.


Contact Your Local Carrier for Blepharoplasty Rule Exceptions


Check with your Medicare carrier, however, because local policies may allow payment for blepharoplasty in some situations. This is a Medicare payment policy issue, explains Michael X. Repka, MD, the American Academy of Ophthalmologys representative to the AMA CPT advisory committee. CPT wont make the distinction between cosmetic and functional.

The two main reasons for medical necessity in lid repair are visual loss and damage to the globe. Visual impairment doesnt occur with lower-lid problems, but if the globe is exposed, the blepharoplasty codes (15820 or 15821) are justified. Blepharoplasty to treat lower eyelid ptosis [374.3] is covered when surgery is needed to prevent ocular exposure and globe damage, according to one local medical review policy (LMRP). The patients medical record must justify that the diagnosis information submitted on the claim accurately reflects the patients condition and the medical necessity for service. A subsequent determination that the medical record is lacking justification will result in a retroactive denial. With blepharoplasty (15820), the ophthalmologist makes an incision under the eyelash line and dissects the skin of the lower lid. The skin is pulled tight, and excess skin is removed. Muscle fascia may be stitched if muscles are sagging.

When excess fat is removed as well, use code 15821. Because these codes are unilateral, append modifier -50 (bilateral procedure) to the second listing for a bilateral procedure.


Document Ectropion and Entropion Repairs


Ectropion and entropion repairs are considered reconstructive when they provide functional benefits, says Sherry Searson, CPC, an independent coding consultant in Ravenel, S.C., specializing in ophthalmology. These procedures are performed to reconstruct an abnormal structure of the eyelid using local or distant tissue. Medical necessity is established by documenting the patients complaints regarding symptoms, by medical history, and by an examination supporting the medical problem with a complaint or diagnosis, such as redness, irritation, scratchiness, severe dryness or eye trauma. With entropion, the eyelashes may touch the surface of the eye, which irritates the eye and could damage the cornea. Ectropion exposes the globe, as with exposure keratitis (370.34), and can damage the eye.

Check your local medical review policy for supported diagnoses and documentation requirements, such as external photos showing the ectropion or entropion. Visual field tests are not always required for ectropion or entropion repair, but are required for blepharoplasty and blepharoptosis repair. In my experience, Medicare has never questioned or asked for medical documentation for entropion or ectropion repair, Searson says.


Use Accurate Diagnosis Codes


The diagnosis code for entropion repair is 374.0x, Roberts says. The fifth digit indicates the type of entropion. For example, use code 374.04 for entropion caused by scar tissue. The primary diagnosis is the entropion, and the secondary diagnosis would be the problem it was causing, such as 370.34 for exposure keratitis.

Ectropion and Entropion Repair Procedures Ectropion and entropion repair codes and procedures are described in this section. Ectropion repair: 67914 repair of ectropion; suture Local anesthetic, no incision, and posterior tissues are foreshortened with absorbable sutures. 67915 repair of ectropion; thermocauterization Local anesthetic, no incision, and posterior tissues are shrunk via cautery. 67916 repair of ectropion; blepharoplasty, excision tarsal wedge Local anesthetic, incision, a section in the shape of a diamond or rhomboid is taken from posterior surface and closed with sutures. 67917 repair of ectropion; blepharoplasty, extensive (e.g., Kuhnt-Szymanowski or tarsal strip operations) Local anesthetic, one incision, and strip of tarsus is inserted in the lateral third. Sutures are passed through the strip. Procedure involves more than skin. Entropion repair: 67921 repair of entropion; suture Local anesthetic, no incisions, and sutures are threaded through inferior fornix or inferior cul-de-sac to the lash line, then tied on the skin side. 67922 repair of entropion; thermocauterization Local anesthetic, no incisions, and tissue shrinkage is accomplished via cautery. 67923 repair of entropion; blepharoplasty, excision tarsal wedge Local anesthetic, two incisions, and a triangular section of tarsus is excised. A piece of muscle is removed, and edges are repaired with sutures. Procedure involves more than just skin. 67924 repair of entropion; blepharoplasty, extensive (e.g., Wheeler operation) Sometimes general anesthesia is used otherwise, local anesthesia, one large incision, and the eyelid margin is severed via deep sutures. A triangular section of tarsus may be removed. Procedure involves more than just skin.