Dermatology Coding Alert

Published on Thu Aug 18, 2005 PDF

 What you don't know can hurt you -- to the tune of $291 per procedure

Don't assume all eyelid procedures are cosmetic. You could be cheating your practice out of insurance reimbursement if the surgery is medically necessary.
 
Dermatologists who perform blepharoplasty know that most insurers, including Medicare carriers, are predisposed to denying payment, and to assuming the procedure is cosmetic. While that's true, there are some myths that are preventing dermatologists from claiming legitimate reimbursement for medically necessary blepharoplasty.

Myth #1: Blepharoplasty procedures are always cosmetic.

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 Kathleen McPherson, clinic manager of the department of dermatology at Texas Tech University's Health Sciences Center in Lubbock.
 
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.
 
(For specific ICD-9 codes to back up medical necessity, see "14 Ways to Show Medical Necessity for Blepharoplasty" on page 69.)
 
But: 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.

Myth #2: All documentation must be submitted along with the original claim.

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.

Myth #3: CPT codes 67901-67908 and 15820-15823 are interchangeable.

 
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 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach), in which the ophthalmologist shortens the levator tendon until the lid is at the proper level.

Myth #4: Blepharoplasty is inherently bilateral.

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 50 (Bilateral procedure) appended, McPherson says. 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 report 15823-50. The carrier multiplies the nonfacility RVUs for 15823 by 1.5 (15.39 RVUs x 1.5 = 23.085).
 
Multiplying that by the conversion factor (37.8975) yields $874.86 before any geographic adjustment ...quot; earning you $291.62 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.