Part B Insider (Multispecialty) Coding Alert

Published on Fri May 12, 2006 PDF

Carriers will cover blepharplasty for functional or reconstructive surgeries

Medicare is prone to deny payment to dermatologists who perform blepharoplasty because it assumes the procedure is cosmetic. But you can win payment if the procedure is medically necessary. Here’s how.

Whether or not a blepharoplasty procedure is always cosmetic depends on the procedure and the patient’s main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done out of medical necessity …quot; but to convince Medicare, you need the right codes and airtight documentation.

Note: Insurers cover blepharoplasty procedures 15822 (Blepharoplasty, upper eyelid) or 15823 (…with excessive skin weighing down lid) when the patient suffers from decreased vision or other specific medical problems, says Kathleen McPherson, clinic manager of the department of dermatology at Texas Tech University’s Health Sciences Center in Lubbock.

Example: Medicare carrier Palmetto’s local coverage determination (LCD) states that it will cover blepharoplasty as functional or reconstructive surgery to correct:

• Visual impairment with near or far vision due to dermatochalasis, blepharochalais or bleharoptosis

• 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.

Hidden trap: CPT Codes 15820 (Blepharoplasty, lower eyelid) and 15821 (…with extensive herniated fat pad) are almost always never payable, since the lower eyelid doesn’t actually impair vision.

Also, don’t get confused by the myth that blepharoplasty is inherently bilateral.

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

If the dermatologist performs blepharoplasty on both upper eyelids, report 15822 or 15823 with modifier 50 (Bilateral procedure) appended, McPherson says. Modifier 50 usually tells the carrier to apply a 150 percent payment adjustment to the claim.