Ophthalmology and Optometry Coding Alert

Question: When our ophthalmologist performs blepharoplasty, I’m often not sure whether the procedure can qualify as medically necessary. What determines whether blepharoplasty procedures are cosmetic?

Indiana Subscriber

Answer: It depends on the procedure and the patient’s main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done due to medical necessity, but your coding and documentation need to support the necessity to prove that the procedures aren’t purely cosmetic.

For blepharoplasty procedures, look to CPT^® codes 15820-15823 (Blepharoplasty …). 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, one insurer states it will cover blepharoplasty procedures and repair of blepharoptosis when performed as functional or reconstructive surgery to correct:

• Congenital ptosis with risk for amblyopia
• Ectropion and entropion
• Symptomatic dermatitis of pretarsal skin caused by redundant upper-lid skin
• Prosthesis difficulties in an anophthalmia socket
• Symptomatic redundant skin weighing down upper lashes
• Visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis. 

But: CPT^® codes 15820 (Blepharoplasty, lower eyelid) and 15821 (… with extensive herniated fat pad) are almost never covered. Insurers believe that excessive skin or fat in the lower eyelids do not usually obscure vision.