Ophthalmology and Optometry Coding Alert

Successfully billing multiple procedures on eyelids depends on using the correct modifiers based on the type of procedure and the lids involved. You have a choice of Modifier 50 (bilateral procedure), -51 (multiple procedures), or -E1 to -E4 (the eyelid modifiers). The E modifiers are the most useful because they link the procedure to a specific eyelid. However, sometimes the E modifiers are not as appropriate as modifier -50 or -51.

Punctal-plug closure is a unilateral procedure. For most payers, you can bill for two lids by using modifier -50 if the same procedure is done on both eyes. For example, if the lower left and lower right puncta are closed with plugs, bill 68761 (closure of the lacrimal punctum; by plug, each) on two lines, with modifier -50 appended to the second. Also, it's a good idea to append the eyelid modifier (-E1 [upper left, eyelid], -E2 [lower left, eyelid], -E3 [upper right, eyelid], or -E4 [lower right, eyelid]) to indicate which lid the procedure is performed on. For Medicare, bill using one line for two lids, with modifier -50 appended (e.g., 68761-50) without the E modifiers.
 
If all four puncta are plugged, use modifier -51 and the eyelid modifiers instead of modifier -50. Billing simply 68761-50 will result in payment for two plug insertions, not four. Bill four-punctal plug procedures on a claim form as follows:
 
Line 1: 68761-E1 
Line 2: 68761-51-E2 
Line 3: 68761-51-E3 
Line 4: 68761-51-E4.

Medicare will pay 100 percent for the first procedure and 50 percent for each of the other three.

Lesion-removal codes (11440-11446), although unilateral, should not be billed with modifier -50 when performed on both eyes. Whether two lesions are removed from one lid, or one lesion from one and one from another, there are still two lesions: Count the lesions, whether they are on one or both eyes.
 
Contact your carriers for their rules on coding multiple lesion removal. Some want you to use modifier -51 or the eyelid modifiers. Some want both. Two examples demonstrate how a claim for multiple lesion removal should read:
 
1. A patient with a 0.4-cm benign lesion on the upper eyelid of the right eye and the lower eyelid of the left eye:
 
Line 1: 11440-E3 
Line 2: 11440-51-E2.

2. A patient with a 0.4- and a 0.7-cm benign lesion on the upper right eyelid:
 
Line 1: 11441-E3 
Line 2: 11440-51-E3.
 
Note: Always list the procedure with the highest reimbursement first when billing multiple procedures because that one is reimbursed at 100 percent.

Alternatively, you can bill 67840* (excision of lesion of eyelid [except chalazion] without closure or with simple direct closure). Use 67840* when the lesion involves more than skin, such as the lid margin, tarsus, and/or palpebral conjunctiva. If the lesion involves mainly the skin of the eyelid, use the lesion codes for the integumentary system (11310-11313, 11440-11446, 11640-11646 and 17000-17004).
 
"CPT guidelines state that the most specific code relating to a procedure should be used," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J. Select the code based on excised tissue. Brink strongly recommends careful documentation of the thickness of the lesion.
 
Another difference between the excision codes (67800-67850) and the integumentary codes (11440-11446) is that while the integumentary codes can be billed by units, the excision codes are billed by the lid. Therefore, if you have many lesions on one lid, you might prefer to bill the integumentary codes with units instead of one excision code.
 
Some experts recommend that any time you excise a lesion, obtain an advance beneficiary notice (ABN) from the patient first. If the lesion is benign, the payer may not cover the procedure on the grounds that it is cosmetic. However, some benign skin lesions may cause medical or vision problems. For example, if there is a risk of infection due to the lesion, or if vision is obscured, the excision is payable. This is a gray area, Brink says, so make sure to document the diagnosis code, which "will help the payer understand whether the removal was cosmetic or medically necessary."
 
Note: Visit www.codinginstitute.com/news/article9.html for a sample ABN form.

When lower eyelid blepharoplasty is performed on both eyes a common occurrence code 15820 (blepharoplasty, lower eyelid) or 15821 ( with extensive herniated fat pad) with modifier -50 appended to the second listing. These codes are unilateral, not bilateral.
 
"Blepharoplasty often occurs either in both lower eyelids or both upper eyelids, and is often treated on both lids at the same time, says Melissa K. Duchak, CPC, practice administrator for Bruce E. Kanengiser, MD, a general ophthalmologist in Piscataway, N.J. "It depends on the surgeon's style, and also on the patient's willingness to travel back for a second procedure."
 
Many ophthalmologists avoid the blepharoplasty codes because they feel that eyelid-repair codes (67914-67924) more accurately describe the medically necessary procedures they perform for entropion or ectropion repair. Some carriers may pay for the blepharoplasty codes if a vision or medical problem is demonstrated.

Contact your Medicare carrier for its policy on epilation (67820*, correction of trichiasis; epilation, by forceps only). Some pay by the lid, some by the eye. CPT indicates the payment is per procedure which means per eye. When performed on both eyes, at a minimum you can bill two lines with modifier -50 appended to the second.
 
For most Medicare carriers and private payers, code epilation with the eye modifiers (-RT, -LT). For example, an epilation of one lash in the upper left lid and three in the lower right lid should be coded 67820-LT on the first line and 67820-51-RT on the second line.
 
For a carrier that pays for epilation by the lid, use the lid modifiers (-E1 to -E4). The above scenario would be coded 67820-E1, and 67820-51-E4.