Dermatology Coding Alert

Published on Sat Aug 08, 2009 PDF

What you don't know can hurt you -- to the tune of $290.

If you assume eyelid procedures are purely cosmetic, you're missing out on reimbursement your practice may ethically deserve.

Tackles these four common myths that often prevent dermatologists from billing medical necessary blepharoplasties.

You could bolster your practice's bottom line.

Reality: It depends on the procedure and the patient's main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done out of medical necessity -- but to convince Medicare, you need the right codes and airtight documentation.

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, says Janet McDiarmid, CPC, CMM, MPC, AFC, APC, CCP, CEO of McDairmid Leasing and past national president of both the AAPC and PAHCOM.

For example, Medicare carrier Palmetto's local coverage determination (LCD) states that they will cover blepharoplasty as functional or reconstructive surgery to correct:

• visual impairment with near or far vision due to dermatochalasis, blepharochalasis, 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.

Beware: CPT codes 15820 (Blepharoplasty, lower eyelid) and 15821 (... with extensive herniated fat pad) are almost never payable, since the lower eyelid does not usually impair vision.

Reality: With many providers and insurers moving toward electronic claims, submitting extensive documentation just isn't always possible. You should, however, keep everything on file in the patient's medical record.

After the carrier receives the claim, it may ask for additional documentation by sending you an additional document request (ADR) letter.

Keep this documentation in your blepharoplasty patient's file:

• history and physical

• operative report

• visual fields

• photographs.

A dermatologist would probably refer a patient to an optometrist or ophthalmologist for visual fields (92081-92083, Visual field examination, unilateral or bilateral, with interpretation and report ...), says Jeffrey Weinberg, MD, director of the Clinical Research Center of the department of dermatology at St. Luke's-Roosevelt Hospital Center in New York City. The tests show the extent of the patient's decreased vision.

Most carriers want two sets of visual fields -- one with the upper eyelid at rest and one with the eyelid taped up to demonstrate an expected improvement. Be sure to get both sets of results from the optometrist or ophthalmologist who performs the tests.

For photographs, carriers usually want prints -- not slides -- showing one or more of these conditions:

• The upper eyelid margin approaches to within 2.5 mm (one-fourth 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.

Reality: Both code sets address the same problem -- reduced fields of vision due to eyelid obstruction.

However, they represent two different underlying causes and two different solutions to the problem. Blepharoplasty (15820-15823) is an excision of skin and fat. The repair codes 67901-67908 (Repair of blepharoptosis ...) represent a revision in the actual muscle, for example, 67904 (... [tarso] levator resection or advancement, external approach), in which the surgeon shortens the levator tendon until the lid is at the proper level.

Reality: This can be an especially costly misperception. CPT codes 15822 and 15823 are inherently unilateral, meaning that the dermatologist will not necessarily perform the procedure on both upper eyelids at once.

If the dermatologist performs blepharoplasty on both upper eyelids, report 15822 or 15823 with modifier E1 (Upper left lid) or E3 (Upper right left), McDiarmid says. You might try modifier 50 (Bilateral procedure) appended.

Modifier 50 usually tells the carrier to apply a 150 percent payment adjustment to the claim.

Example: In the office, the dermatologist removes excess skin weighing down both upper eyelids. You choose to report 15823-50. The carrier multiplies the nonfacility RVUs for 15823 by 1.5 (16.28 RVUs x 1.5 = 24.42). Multiplying that by the 2009 conversion factor ($36.0666) yields $880.75 before any geographic adjustment -- earning you $293.59 more than if you had reported the procedure unilaterally.

If the dermatologist only performed blepharoplasty on one eye, append modifier LT (Left side) or RT (Right side) to the CPT code to indicate which eye he operated on.