Ophthalmology and Optometry Coding Alert

Ophthalmologists cannot get reimbursed by Medicare when they perform blepharoplasty on the lower eyelid for cosmetic reasons, such as removing bags under the eyes (15820-15821). But they can be reimbursed if the blepharoplasty is medically necessary, such as for repair of entropion or ectropion (374.1x), by using the eyelid repair codes (67914-67924). Entropion (lower-lid lash line turns toward the eyeball) and ectropion (lower lid droops and turns away from the eyeball) can damage the eye and must be repaired surgically.

Lise Roberts, vice president of Health Care Compliance Strategies, a coding and compliance consultant based in Jericho, N.Y., says, Most ophthalmologists know to stay away from the blepharoplasty codes [15820-15821]. Theyve experienced payment problems with them, and the entropion and ectropian repair codes describe the surgical procedure more accurately. Medicare will never pay for 15820 or 15821, says Deborah Rogers, COT, clinic manager for Andersen Eye Associates of Saginaw, Mich. These codes are strictly for cosmetic surgery, such as removing droopy skin or bags under the eyes.


Contact Your Local Carrier for Blepharoplasty Rule Exceptions


Check with your Medicare carrier, however, because local policies may allow payment for blepharoplasty in some situations. This is a Medicare payment policy issue, explains Michael X. Repka, MD, the American Academy of Ophthalmologys representative to the AMA CPT advisory committee. CPT wont make the distinction between cosmetic and functional.

The two main reasons for medical necessity in lid repair are visual loss and damage to the globe. Visual impairment doesnt occur with lower-lid problems, but if the globe is exposed, the blepharoplasty codes (15820 or 15821) are justified. Blepharoplasty to treat lower eyelid ptosis [374.3] is covered when surgery is needed to prevent ocular exposure and globe damage, according to one local medical review policy (LMRP). The patients medical record must justify that the diagnosis information submitted on the claim accurately reflects the patients condition and the medical necessity for service. A subsequent determination that the medical record is lacking justification will result in a retroactive denial. With blepharoplasty (15820), the ophthalmologist makes an incision under the eyelash line and dissects the skin of the lower lid. The skin is pulled tight, and excess skin is removed. Muscle fascia may be stitched if muscles are sagging.

When excess fat is removed as well, use code 15821. Because these codes are unilateral, append modifier -50 (bilateral procedure) to the second listing for a bilateral procedure.


Document Ectropion and Entropion Repairs


Ectropion and entropion repairs are considered reconstructive when they provide functional benefits, says Sherry Searson, CPC, an independent coding consultant in Ravenel, S.C., specializing in ophthalmology. These procedures are performed to reconstruct an abnormal structure of the eyelid using local or distant tissue. [...]