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Ophthalmology and Optometry Coding Alert

Show Blepharoplasty Necessity With Careful Documentation

Published on Tue Apr 01, 2003

Don't let payments droop when it comes to eyelid surgery, because it is possible for you to ensure reimbursement through meticulous documentation, thorough testing, and patient awareness.

"Blepharoplasty is a procedure performed on the eyelids to remove excess fat and/or tissue from the eyelids to create or recreate a visual field," says Fiona Lange, CPC, with Danbury Eye Physicians, a nine-physician multi-specialty practice in Danbury, Conn.

Most patients who come into Lange's office suffer from a visual field defect in their superior vision. However, the problem with coding for this procedure is that most insurance carriers assume it is purely cosmetic, like an eyelid tuck or eyelid lift, and refuse payment. Therefore, coders often run into the issue of proving the procedure was medically necessary, not cosmetic.

First, you need to take a look at your local medical review policy (LMRP), which will save you from unnecessary coding pain. Most LMRPs offer guidelines to help you determine when to bill for blepharoplasty and how to show medical necessity. For example, Regence Blue Cross Blue Shield of Utah's LMRP explicitly states that blepharoplasty will be considered covered when performed as a functional surgery to correct the following conditions:

  • Visual impairment with near or far vision due to dermatochalasis, blepharo-chalasis, or blepharoptosis
  • Symptomatic redundant skin weighing down on upper lashes
  • Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper-lid skin
  • Prosthesis difficulties in an anophthalmia socket.

    Follow Three Steps to Show Medical Necessity

    Most carriers approve medical necessity for blepharoplasty on a case-by-case basis, and each insurance carrier tends to have its own policy regarding this issue, Lange says. In the past, Medicare required coders to send in all the information that showed the procedure was medically necessary; now they expect the information to be in the charts, says Jennifer Simpson, CPC, a coder in Lexington, Ky. In addition to a complete history, examination, and operative report, you should be sure to document the following:
    1. Patient Complaint. One general criterion used to prove necessity is the patient complaint, Lange says. The patient has to present in the office complaining of specific problems in his or her day-to-day life. Lange most commonly sees complaints of heaviness of the eyelids, the need to adjust one's head to see properly, the need to physically lift one's eyelids to read, and reductions in peripheral vision while driving.
    2. Visual Fields. Many Medicare carriers and other insurance companies require the physician to test the patient's visual fields to see how they appear naturally. Then he does fields, while taping the eyelids up, to determine the improvement that would result from surgery, Simpson says. Most LMRPs require that documentation demonstrate a 12 to 30 percent improvement between neutralized and elevated superior visual fields (taped and untaped).
    3. Photographs. Last, the patient's chart must include photographs of the problem eye(s). According to Regence BlueCross BlueShield of Utah, photographs must demonstrate that the upper eyelid margin approaches to within 2.5 mm of the corneal light reflex, the upper eyelid skin rests on the eyelashes (lid lash touch), and the upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.

    Use ABN in Absence of Proper Diagnosis

    So how do you avoid denials, and what should you do if you are denied? Lange says she does not receive many denials from Medicare because her practice is meticulous with documentation and conservative with treatment. If there is any doubt as to whether the patient's problem would meet medical necessity, she has him sign an advance beneficiary notice (ABN) up front.

    The presence of a signed ABN is one of the factors that indicates that you need to append modifier -GA Waiver of liability statement on file). If the payer denies the claim for reason of medical necessity, the patient will receive an explanation of benefits stating "if your physician/supplier did not inform you that this service may be non-covered, you may not be responsible for payment." If the patient contacts Medicare and says he was not informed, then the practice would need to provide proof of the ABN.

    There are certain signs to look for when deciding whether a patient should sign an ABN. One of the most pertinent criteria is the lack of a diagnosis code that your carrier deems proof of medical necessity. Blue Cross and Blue Shield of Tennessee's LMRP lists several codes that support medical necessity:

  • 374.30 Ptosis of eyelid, unspecified
  • 374.31 Paralytic ptosis
  • 374.32 Myogenic ptosis
  • 374.33 Mechanical ptosis
  • 374.34 Blepharochalasis
  • 374.87 Dermatochalasis
  • 743.61 Congenital ptosis of eyelid
  • V52.2 Fitting and adjustment of artificial eye.

    Don't Forget Eyelid Modifiers

    Most carriers require you to use -LT and -RT modifiers with your blepharoplasty codes. Also, remember that blepharoplasty is a unilateral procedure, so you should append modifier -50 (Bilateral procedure) when the doctor performs it on both eyelids, Simpson says.

    For example, a patient presents with excessive skin of the left eyelid, which does not cause impaired vision or meet any other criteria established by the carrier to show medical necessity. The physician diagnoses lid retraction (374.41). He decides the procedure is not medically necessary but primarily cosmetic, so the patient signs an ABN. The ophthalmologist performs a blepharoplasty of the upper eyelid skin, 15822 (Blepharoplasty, upper eyelid). You should bill 15822-GA-LT. You can also use the diagnosis code V50.1 (Cosmetic surgery, eye).

     

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