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Bleph/ with Ptosis Repar

H

hmccullough100@gmail.com

Contributor
Messages
17
Location
Greensburg, Pennsylvania
I have a physician who does Upper Eye Ptosis repairs along with functional Blepharoplasties. I believe you can only get paid on one of these even with a 59 modifier. Anyone have thoughts on this? Thank you for any input you might have.
 
I'm confused. What type of 'repair' are you coding? A ptosis repair is generally coded as a blepharoplasty. If you are coding the repair from the 12xxx or 13xxx section of CPT, you are unbundling. You can check for sure by looking at the CCI edits.
 
He actually does cpt code 67904 along with 15823 but according to cci edits they will only pay the one code. This has confused me and on another thread I read they both can be billed with a 51 modifier on one. However, if you use encoder it shows them not being able to be billed together.... Hope that explains my dilemma....
 
NCCI Edit Results:
Edit exists with 67904. 15823 is a Column 2 code. If both 67904 and 15823 are submitted, only 67904 will be paid.
- This edit CAN be overridden via CCI-associated modifiers WHEN APPROPRIATE.
- Rationale: Mutually exclusive procedures
- Effective 4/1/2009

The only way you'd be able to report both is if they were on separate eyelids.
 
Pam Warren said:
NCCI Edit Results:
Edit exists with 67904. 15823 is a Column 2 code. If both 67904 and 15823 are submitted, only 67904 will be paid.
- This edit CAN be overridden via CCI-associated modifiers WHEN APPROPRIATE.
- Rationale: Mutually exclusive procedures
- Effective 4/1/2009

The only way you'd be able to report both is if they were on separate eyelids.
Click to expand...
We are having issues with a doc not accepting that she cannot charge for that bleph as a cosmetic charge if the ptosis is same eye. She is using the 2017 CMS manual as backup but the AAO site says you can't when the 2017 manual says you can. What are your resources or thoughts on charging the patient for the bleph when done with Ptosis? Medically necessary.
 
My thoughts? Well, it's unfortunate for the patient to unbundle the charges. If the patient's insurance won't pay both, and the provider is credentialed with that payer, you cannot balance bill the patient. Changing the diagnosis to a cosmetic one just to get paid is hovering really close to a false claim. If the ptosis repair truly is cosmetic, then the discussion should be held with the patient prior to the surgery.
 
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