Ophthalmology and Optometry Coding Alert

Question: Our oculoplastic surgeon performed levator resection and blepharoplasty on both upper eyelids in the same surgical session. Can I code these procedures together (15823 and 67904), or are they considered bundled? Which one should I code as the primary procedure?Indiana SubscriberAnswer: If the oculoplastic surgeon performs the blepharoplasty (bleph) with excessive weight (15823, Blepharoplasty, upper eyelid; with excessive skin weighting down lid) on one eye and the blepharoptosis (ptosis) repair (67904, Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) on the other eye, you may be able to report both codes by using modifiers RT or LT and 59 (Distinct procedural service) on 15823 to designate a separate site from 67904. Otherwise, you should report only 67904.The Correct Coding Initiative (CCI) has made 15823 and 67904 mutually exclusive, meaning Medicare believes that the two procedures would not typically be performed at the same operative session. In other [...]