Ophthalmology and Optometry Coding Alert

Question: How do we know when a blepharitis procedure is considered cosmetic?

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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 to support medical necessity and convince insurers, you need to submit the correct codes and airtight documentation.

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, insurer United Healthcare Oxford states it will cover blepharoplasty procedures and repair of blepharoptosis when the following criteria are met:

• Ptosis has been ruled out as the primary cause of visual field obstruction
• Clear color photographs show that the extra skin is the primary cause of visual field obstruction.
• The patient must have a Functional/Physical Impairment complaint directly related to an abnormality of the eyelid(s)
• Excess skin (dermatochalasis/blepharochalasis) touches the lashes
• Automated peripheral or superior visual field testing, with the eyelid skin taped and untaped, showing improvement of 30% or more.

Keep in mind: 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.