Ophthalmology and Optometry Coding Alert

Question: Can we get paid for adult-strabismus surgery or is this always considered cosmetic?

Nebraska Subscriber

Answer: It doesn't matter how good-looking your claims for adult-strabismus surgery are if the diagnosis codes don't reflect medical necessity, they won't be reimbursed.

Providing the necessary documentation to demonstrate medical necessity is particularly important if the service is for adult strabismus, because adults have typically had the strabismus for several years without requiring surgery. Most carriers are of the opinion that if an adult has had uncorrected diplopia for many years, typically since childhood, strabismus surgery will not succeed in improving or correcting the patient's diplopia and therefore is cosmetic and not covered.

Ophthalmologists and many interested parties continue to push for coverage of strabismus surgery in adults, citing social prejudices and disadvantages that come with misalignment of the eyes. Many also argue that strabismus surgery in adults is more reconstructive than cosmetic as grounds for coverage and more often than not relieves visual confusion or diplopia, results in sensory fusion and expands patients' visual fields.

If you are going to submit a claim for strabismus surgery for a patient 17 years of age or older, consult with your local carrier first to determine how the carrier handles these claims. You may be required to submit documentation of preoperative evaluations that include descriptions of visual function such as vision with and without glasses, and prognosis for stereopsis. Carriers may also have patient complaint requirements for example, the strabismus interferes with daily activities.

If your carrier considers claims for adult-strabismus surgery on an individual basis, it is imperative that you ask for a list of the acceptable, covered ICD-9 and CPT codes.