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Blepharoplasty code clarification needed

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Hi. Would it be safe to say that the primary codes in this set could be considered "cosmetic", and the secondary codes "medically necessary" because the field of vision is likely being affected?:confused:
 

thomas7331

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What do you mean by 'primary' and 'secondary' codes? Either way, whether a service is cosmetic or medically necessary is something that is determined based on physician assessment of patient needs and/or by payer policies - CPT codes are never cosmetic or not in and of themselves. In this case, whether or not the field of vision is affected is usually one of the main criteria that payers use to determine whether or not to allow coverage for the procedure, but the code will be selected on what actual procedure is performed.
 
Messages
6
Best answers
0
What do you mean by 'primary' and 'secondary' codes? Either way, whether a service is cosmetic or medically necessary is something that is determined based on physician assessment of patient needs and/or by payer policies - CPT codes are never cosmetic or not in and of themselves. In this case, whether or not the field of vision is affected is usually one of the main criteria that payers use to determine whether or not to allow coverage for the procedure, but the code will be selected on what actual procedure is performed.
What I meant by primary and secondary is that they are described a little differently. 15820 doesn't mention whether the fat pad is "extensive", and 15822 doesn't indicate if the skin is weighting the lid down to the extent of being "extensive". Because of that, am I wrong to assume that they aren't "extensive", so they are probably not, in most cases, affecting the field of vision? The reason I'm asking may help.. I work for an insurance company. Currently we don't require PreAuth (PA) on any of the 4 codes, we just pay them at a 50% benefit and don't look at any of them because the administration cost outweighs the cost to the plan. I'd like to propose to my company that we pay 15821 and 15823 under regular medical benefits (80% after ded, etc., whatever the group/employer has chosen for their outpatient surgery benefit coverage), without PA, but keep paying the 15820 and 15822 at 50% with no PA and the provider or member can appeal for the higher benefit if they can show the visual field was affected, even though the skin or fat pad wasn't "extensive". Does that help? I'm just looking for an opinion on my logic here. If I'm totally off then that's cool, let me know. Thank you!
 

thomas7331

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Yes, that makes sense, I agree with your logic that 15821 and 15823 would be less likely than 15820 and 18522 to be cosmetic due to the complicating factors in the code descriptions. Of course, that's making the assumption that providers are choosing the correct codes and reporting correctly. However, from my experience, it's very hard to make generalizations like this without reviewing records - coding decisions don't work well in a hypothetical space, so to speak. If you want to get an accurate sense of whether or not this is the case and what the financial impact would be for such a change, I think there's no substitute for sampling some actual records against your claims and seeing what is really going on. Claims data is not always a reliable way to gauge what is actually what is going in your population. Hope that may help some.
 
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