Ophthalmology and Optometry Coding Alert

Misinterpreting the operative report, or failing to prove medical necessity, could cost you over $600 If you code blepharoptosis repair procedures, you have your hands full making sure that your claims are backed up with proof of medical necessity. We've outlined the keys for determining the correct CPT codes for the top-six oculoplastic procedures below.

To correctly code oculoplastic surgery on eyelids, you need detailed information about the surgical techniques the ophthalmologist used, as well as the specific anatomic sites involved. Getting a single detail wrong could prove costly to your practice.

Many of the blepharoptosis repair codes (67901-67908, Repair of blepharoptosis ...) describe procedures that seem almost identical. There are key differences, however, that will help you choose the correct code for the procedure your ophthalmologist performed, experts say.

Beware: Adding to the difficulty is the fact that Medicare often questions the medical necessity of oculoplastic procedures, especially blepharoptosis repair, says Lolita Jones, RHIA, CCS, an independent coding consultant in Fort Washington, Md. Codes 67901-67911 represent procedures that physicians may also perform for strictly cosmetic purposes, and because of this Medicare may question whether to cover these procedures. Be sure your documentation includes relevant medical history, visual field test results, external photographs, and physical examination records and check with your local carrier for its specific requirements.

Note: For more information on establishing medical necessity for blepharoptosis repairs, see "11 Ways to Show Medical Necessity for Ptosis Repair" later in this issue. Procedure 1: Frontalis Fixation AKA: Frontalis suspension, frontalis sling Code: 67901 (... frontalis muscle technique with suture or other material) Look for: The key to this procedure is the phrase "suture or other material" in the code description, Jones says. In this procedure, the ophthalmologist passes a needle equipped with threadlike material through incisions in the brow and eyelid, creating a sling to support the drooping eyelid. Possible suture materials include preserved and autogenous fascia lata, #40 silicone bands, silicone rods and prolene sutures, Jones says. Procedure 2: Frontalis Fixation With Fascial Sling AKA: Frontalis suspension Code: 67902 (... frontalis muscle technique with fascial sling [includes obtaining fascia]) Look for: "This procedure is almost exactly the same as that for code 67901," Jones says. The difference? The ophthalmologist uses a sling of fascia lata - thin fibrous tissue from the thigh - to suspend the drooping eyelid. He may also use irradiated fascia taken from cadavers. Only use 67902 if you confirm that the ophthalmologist used fascia lata tissue.

Don't miss: The description for 67902 states, "includes obtaining fascia." "You shouldn't have a separate code - for example, from the 20000 section of the CPT code book - for the harvesting of the fascia," Jones says. "That's included in the description itself." Procedure [...]