Ophthalmology and Optometry Coding Alert

Document medical necessity and save $500 per procedure

Blepharoplasty and ptosis repair can be lucrative procedures - if you can meet requirements like keeping visual field data in the patient's records and appending the proper modifiers for bilateral procedures. Take a look at the experts' answers to your most frequently asked questions about these repair procedures. How can we prove that the ptosis repair is medically necessary?Because brow ptosis repair and blepharoplasty can be done for cosmetic reasons many insurers automatically assume that CPT codes 67900-67908 are not medically necessary. You need to document that the ptosis excess fat or excess tissue is impairing the patient's vision says Debby Campbell CPC coding specialist for Slingsby & Wright Eye Care in Rapid City S.D. ""We do visual fields "" Campbell says ""and we always have pictures"" in the medical record.

The ophthalmologist does the visual fields test twice Campbell says - once normally and once with the extra fat or tissue taped out of the way of the patient's eyes to simulate surgery results.

Tip: Most local medical review policies (LMRP) require a 12 to 30 percent improvement between untaped and taped visual fields.

LMRPs may vary in what they want photos to show but CIGNA Healthcare's policy is typical. ""Photographs should demonstrate one or more of the following "" CIGNA says:

 The upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex.

 The upper eyelid skin rests on the eyelashes.

 The upper eyelid indicates the presence of dermatitis.

 The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.

The good news: You don't have to submit all of these things to get reimbursed. Many offices typically ask for preauthorization from the carrier but usually ""nothing needs to be sent in to get preauthorization "" says Regan Bode CPC clinic administrator at the Northwest Eye Clinic in Lynden Wash. You just have to have documentation on file in case your bleph claims are ever audited she says. Carriers will mainly look at the diagnosis to make sure it establishes medical necessity. In the event of an audit she says ""you would just need to be able to show them the fields and the photos - your documentation that it was impairing their vision.""

Note: For a list of ICD-9 codes that commonly support medical necessity for blepharoplasty and brow repair see ""Show Medical Necessity for Ptosis Repair"".

Can we bill twice for the taped and untaped visual fields? ""You can only bill for it once "" Bode says. But you can report a code that includes the work of drawing two isopters (the graphic representation of the patient's field of vision). Use 92082 (Visual field [...]