Ophthalmology and Optometry Coding Alert

Don't let payments droop when it comes to eyelid surgery, because it is possible for you to ensure reimbursement through meticulous documentation, thorough testing, and patient awareness.

"Blepharoplasty is a procedure performed on the eyelids to remove excess fat and/or tissue from the eyelids to create or recreate a visual field," says Fiona Lange, CPC, with Danbury Eye Physicians, a nine-physician multi-specialty practice in Danbury, Conn.

Most patients who come into Lange's office suffer from a visual field defect in their superior vision. However, the problem with coding for this procedure is that most insurance carriers assume it is purely cosmetic, like an eyelid tuck or eyelid lift, and refuse payment. Therefore, coders often run into the issue of proving the procedure was medically necessary, not cosmetic.

First, you need to take a look at your local medical review policy (LMRP), which will save you from unnecessary coding pain. Most LMRPs offer guidelines to help you determine when to bill for blepharoplasty and how to show medical necessity. For example, Regence Blue Cross Blue Shield of Utah's LMRP explicitly states that blepharoplasty will be considered covered when performed as a functional surgery to correct the following conditions:
Visual impairment with near or far vision due to dermatochalasis, blepharo-chalasis, 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. Follow Three Steps to Show Medical Necessity Most carriers approve medical necessity for blepharoplasty on a case-by-case basis, and each insurance carrier tends to have its own policy regarding this issue, Lange says. In the past, Medicare required coders to send in all the information that showed the procedure was medically necessary; now they expect the information to be in the charts, says Jennifer Simpson, CPC, a coder in Lexington, Ky. In addition to a complete history, examination, and operative report, you should be sure to document the following:
1. Patient Complaint. One general criterion used to prove necessity is the patient complaint, Lange says. The patient has to present in the office complaining of specific problems in his or her day-to-day life. Lange most commonly sees complaints of heaviness of the eyelids, the need to adjust one's head to see properly, the need to physically lift one's eyelids to read, and reductions in peripheral vision while driving.
2. Visual Fields. Many Medicare carriers and other insurance companies require the physician to test the patient's visual fields to see how they appear naturally. Then he does fields, while taping the eyelids up, to determine the improvement that would result from surgery, Simpson says. Most LMRPs require that documentation demonstrate a 12 to 30 percent improvement [...]