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15823 and 67904 on same eye - We have patients

  1. #1
    York, PA
    Default 15823 and 67904 on same eye - We have patients
    Medical Coding Books
    We have patients who have the levator resection (67904) and the excision of excess skin/fat (15823) done on the SAME EYE. For Medicare, there is an NCCI bundle, so only one code can be submitted. 15823 has the higher RVU, thus that one should be coded for Medicare, correct? But for COMMERCIAL payers, can both 15823 59 and 67904 59 be submitted? Is there a policy stating any of this?

    Any response will be greatly appreciated.
    Thank you.

  2. #2
    Hollywood, CA

    Should help you with your question
    Sal Valdepena, CCS, CEDC

  3. #3
    Columbia, MO
    since most if not all commercial payers also follow the CCI edits then I would say no you cannot bill both, you are allowed to bill the procedure with the higher RVU, but be sure you have it correct.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    I disagree, you should be able to bill both as long as both are documented. See below from August 2011 issue of CPT assistant.


    The CPT Assistant Newsletter (September 2000; p 7) cited the following regarding the reporting of blepharoplasty and blepharoptosis:

    The fundamental difference between the blepharoplasty and the blepharoptosis repair is that a blepharoplasty is surgery on the skin of the upper eyelid and the orbital fat, while a blepharoptosis repair is surgery on the levator muscle of the eyelid. These procedures may either be done independently or together on the same eye depending upon the surgical indication. This would occur when the upper eyelid has redundant skin and the levator muscle is unable to elevate the eyelid to the normal position. When these two procedures are done on the same upper eyelid, both procedural codes are needed to accurately describe the procedure. The coder should include the multiple procedures Modifier 51 with the second code.


    The instruction reported in the September 2000 issue of the CPT Assistant Newsletter remains correct, ie, it is still appropriate to report code 15823, Blepharoplasty, upper eyelid; with excessive skin weighting down lid, in addition to code 67904, Repair of blepharoptosis; (tarso) levator resection or advancement, external approach, when both procedures are performed on the same eyelid. It is also appropriate to append modifier 51, Multiple Procedures, to the second code.

    Third-party payer guidelines may, however, differ from CPT coding guidelines, as both coverage and payment policy is determined by individual insurers and third-party payers. For reimbursement or third-party payer policy issues, please contact the applicable payer. "

    Lorrae Aker, CPC

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