Ophthalmology and Optometry Coding Alert

To prove that blepharoplasty is medically necessary, you have to perform two sets of visual fields per patient -- but many Medicare carriers will pay only for one set.

You may never see full reimbursement for your work, but here's how you can code to get most of what you're due. Before approving blepharoplasty payments, insurers look for proof that the drooping eyelids are interfering with the patient's field of vision -- accomplished by performing taped and untaped visual field (VF) tests (92081-92083).

Ophthalmologists must perform a visual field test with the patient's eyelids taped out of the way (in addition to a standard VF), showing what the postoperative field of vision will be, says Becky Zellmer, CPC, COTA, MBS, CBCS, medical billing and coding supervisor for Suby, Von Haden and Associates in Neenah, Wis.

The visual field should demonstrate a minimum of 12 degrees or 30 percent loss of the upper field of vision with upper lid skin and/or upper lid margin, says Zellmer, who led the "Effective Strategies for Blepharoplasty Coding" seminar at The Coding Institute's recent conference.

So how can you be paid fair reimbursement when your ophthalmologist performs two visual field tests?

Scenario: A patient wants to have part of a droopy eyelid removed because of a decreased field of vision. In order to determine that the droopy eyelid was indeed the cause of the decreased vision, the ophthalmologist performs taped and untaped visual field tests.

Key: Ophthalmologists should check with payers regarding acceptable coding for pre-blepharoplasty visual fields, advises David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. "In spite of the fact that all the carriers are supposed to be doing the same thing, this is a prime example that it just isn't happening across the board," he says. "There are many different methods of coding and billing being required out there."

Best way: You should use 92082 (Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination ...) to show the work of drawing two isopters (the graphic representation of the patient's field of vision).

Alternative: Some carriers will reimburse you for both tests because they mandate two VF tests, which requires extra work by the ophthalmologist. In this case,you should append modifier 76 (Repeat procedure or service by same physician) to the second test and report 92082 and 92082-76. You can add comments in Block 19 of the claim form (or the electronic equivalent) to indicate "taped and untaped," notes Zellmer.

Alternative strategy: One insurer, Pennsylvania's Highmark Blue Shield, directs you toward an unlisted procedure code. "Codes 92081-92083 should be used as appropriate to report 'untaped' automated visual field examinations," says Highmark's policy on "Automated Visual Field Examinations." "Code 92499 [Unlisted ophthalmological service or procedure] should be used to report a 'taped' automated visual field examination."

Smart: Check with your local carrier to determine which appropriate coding and billing scenarios it has determined as acceptable.

Exception: Not all carriers require two sets of visual fields. For example, Part B carrier TrailBlazer published a local coverage determination in September 2004 stating that one untaped set of visual fields "recorded to demonstrate an absolute superior defect to within 15 degrees of fixation" is sufficient.

One thing to watch for is the chief complaint. The patient's chief complaint may be only cosmetic and a cosmetic complaint is not something that will drive a medically necessary procedure, says Gibson. But if the patient complains of problems seeing due to droopy lids, that's another story -- "so here's a great time to think creatively and dig a little deeper into the case history," he suggests. "Remember, patients don't always understand the need for medical necessity or that droopy lids can interfere with their vision."

Example: A patient who notes that she has to hold her head back to see when she drives, or that she has to physically hold her lids up in order to read, is indicating a medical problem, not a cosmetic one. Medicare requires the documentation to be able to evaluate whether the procedure was cosmetic or medical.

To keep your office on the safe side, give an advance beneficiary notice to any blepharoplasty cases. Append modifier GA (Waiver of liability statement on file) to any medically necessary claims.

"You would still use modifier GA when submitting a claim for cosmetic claims," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. "The GA modifier is letting Medicare know that the patient has been informed that he may be financially responsible for a Medicare-covered service that may be considered cosmetic and not medically necessary."

The diagnosis code on the claim should indicate that the ophthalmologist performed the service for cosmetic reasons (V50.1, Unacceptable cosmetic appearance) and not due to a medically indicated diagnosis, Mac advises.

The patient will receive a denial stating that he was informed in advance of non-coverage and is financially responsible for payment of the procedure.

Do this: "It is imperative that the office obtains a properly executed ABN prior to the procedure, gives the patient a copy of the signed ABN, and appends modifier GA to the procedure," stresses Mac. "If one of these steps is missed or not properly executed, the practice may not be able to collect payment from the patient."