Ophthalmology and Optometry Coding Alert

Read these frequently asked questions before coding your next eyelid procedure claim.

Coding for eyelid procedures can be tricky, and even the most experienced coders have questions about clean claims and reimbursement. Read on for our expert answers to your frequently asked questions.

Q: What determines whether blepharoplasty procedures are cosmetic?

A: 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 Emblem Health states it will cover blepharoplasty procedures and repair of blepharoptosis when performed as functional or reconstructive surgery to correct:

• Congenital ptosis with risk for amblyopia
• Ectropion and entropion
• Symptomatic dermatitis of pretarsal skin caused by redundant upper-lid skin
• Prosthesis difficulties in an anophthalmia socket
• Symptomatic redundant skin weighing down upper lashes
• Visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis. 

But: 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.

Q: Do we need to do two visual field tests? How do we code for that?

A: Most carriers want you to document the improvement in the visual field that will result from the surgery. The ophthalmologist does the visual fields (VF) test twice: once in the normal fashion and once with the eyelids taped to pull the drooping tissue out of the way of the patient’s eyes and to simulate surgery results, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. The test is meant to show that vision will improve if the eyelid problem is solved — with tape temporarily, with surgery more permanently.

Tip: Many carrier policies require a 12 to 30 percent improvement between the two VF tests. They may also have specific criteria that the tests must show. For example, United HealthCare says the photos need to demonstrate “one or more” of the following:

• The upper eyelid margin approaches to within 2.5 mm (¼ 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.

Billing: Because your ophthalmologist performs the VF testing twice, you may be tempted to code the service twice. Unfortunately, with some payers you can bill only once for the VF test. You should use CPT® code 92082 (Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination [e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33]) to show the work of drawing two isopters (the graphic representation of the patient’s field of vision). 

Alternative: Some carriers will reimburse you for both tests because they mandate two VF tests, which requires extra work by the ophthalmologist. In this case, you should append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to the second test and report 92082 and 92082-76. You can add comments in Block 19 of the claim form to indicate “taped and untaped.”

Best bet: Ask your local carrier how you should code these two tests.

Q: What’s the difference between 15820-15823 and 67901-67908?

A: 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.

Q: What modifiers do we need to append to the CPT® codes?

A: Blepharoplasty codes 15820-15821 (Blepharoplasty, lower eyelid …) and 15822-15823 (Blepharoplasty, upper eyelid …) all specify an upper or lower eyelid. Therefore, you should only need to specify the particular eyelid — right or left — that your ophthalmologist fixed. To do so, you’ll add modifier LT (Left side) or RT (Right side) to the blepharoplasty procedure code. For example, 15822-LT could only describe blepharoplasty performed on the upper left eyelid.

Alternative: Again, there may be different policies among your individual carriers on how to use modifiers to report the procedure. Some carriers may want you to use an eyelid modifier with the blepharoplasty code. 

Example: A carrier may require you to report blepharoplasty on the upper left eyelid with 15822-E1. If the ophthalmologist performs blepharoplasty on both upper eyelids, you may also need to append modifier 50 (Bilateral procedure).

Remember: The descriptions for 67901-67908 (Repair of blepharoptosis …) do not specifically mention upper or lower eyelids. But blepharoptosis is defined as “drooping of the upper eyelids,” so your ophthalmologist would perform a blepharoptosis repair procedure only on the patient’s upper eyelids. Again, some carriers accept modifiers LT or RT, whereas others want you to use E1-E4.

Bilateral rules: CPT® codes 15822 and 15823 are inherently unilateral, meaning that the ophthalmologist will not necessarily perform the procedure on both upper eyelids at once.

If the ophthalmologist performs blepharoplasty on both upper eyelids, report 15822 or 15823 with modifier 50 (Bilateral procedure) appended. Modifier 50 usually tells the carrier to apply a 150 percent payment adjustment to the claim. Some payers may prefer you to report the procedure on two lines with modifiers LT (Left side) and RT (Right side).

Example: In the office, the ophthalmologist removes excess skin weighing down both upper eyelids. You report 15823-50. The carrier multiplies the nonfacility RVUs for 15823 by 1.5 (17.81 RVUs in 2014 x 1.5 = 26.715).

Multiplying that by the 2014 conversion factor (35.8228) yields $957.01 before any geographic adjustment, earning you $319.01 more than if you had reported the procedure unilaterally (17.81 x 34.023 = $638.00).

If the ophthalmologist only performed blepharoplasty on one eye, report 1582x on one line with modifier LT or RT appended to indicate which eye he operated on.