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Optometry Coding & Billing Alert


CMS: Blepharoplasty Claims the Cause of Numerous Errors

No visual field testing? No Medicare payment, latest compliance newsletter says.

You might be collecting Medicare payments for your blepharoplasty procedures without incident—but that doesn’t necessarily mean you’re billing them properly.

That’s the word from a recent CMS review of blepharoplasty claims that was published in the October 2016 edition of the Medicare Quarterly Provider

Compliance Newsletter. The agency pored over claims billed with 15823 (Blepharoplasty, upper eyelid; with excessive skin weighting down lid) and created a report outlining the most common and egregious errors.

Insufficient Documentation Plagues Claims

Medicare contractors who reviewed blepharoplasty claims found that the most common error was insufficient documentation, which included the following issues:

  • Missing authenticated or signed visual field testing
  • No pre-surgical photographs that were signed or authenticated and interpreted
  • Missing op notes
  • No documentation of the medical necessity of the procedure
  • Missing physician’s signature on the notes

If you fail to have any of these items in your files for blepharoplasty, the payer could deny payment, or request reimbursement back if you’ve already collected for the procedure. CMS outlines one such incidence of this in the Compliance Newsletter, in which a provider submitted notes to support his blepharoplasty, but didn’t sign the visual field testing report, so the payer requested that the doctor had to refund his reimbursement to the insurer.

According to the Compliance Newsletter, the local coverage decision (LCD) in this example requested documentation of “a functional deficit or disturbance secondary to eyelid and/or brow abnormalities, such as interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or driving.”)

However, without an authenticated visual field test or documentation of the visual impairment caused by the excess skin, the payer was unable to let the doctor keep the reimbursement in this case.

Follow These FAQs for Successful Payment

To ensure that you’re properly reporting blepharoplasty services, check out the following three frequently-asked questions along with the answers straight from Medicare payers that will keep your reimbursement flowing.

1. Are Photos Required?

Many insurers, including most Medicare contractors, require you to take photographs documenting the excess skin. WPS Medicare’s policy, for example, says the following: “Photographs and medical record documentation must demonstrate at least one of the following (Digital or film photographs are acceptable) - For Blepharoplasty Repair: Frontal photos are needed to demonstrate redundant skin on the upper eyelids:

       a. Upper eyelid skin resting on the eyelashes or over eyelid margin
       b. Upper eyelid dermatitis secondary to redundant skin
       c. Dermatochalasis

You’ll want to retain the photographs in the patient’s file, and include images of the patient’s eyes, both taped and untaped, to provide medical necessity for the procedure.

Other payers may have even more specific requirements for your photographs. Noridian Medicare, for example, says you must have high-quality detailed photographs showing the “redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the ‘pseudo’ margin produces a central ‘pseudo-MRD’ of 2.0 mm or less, or redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in corresponding gaze.”

In addition, Noridian wants to see images where the patient’s head is in a parallel plane to the camera rather than being tilted. “Unless medial/lateral gaze is required to demonstrate a specific deficit, photos should be with gaze in the primary position, looking straight ahead,” Noridian notes. “Oblique photos are only necessary if needed to better demonstrate a finding not clearly shown by other requested photos.”

2. Which Diagnosis Codes Will Reveal That Blepharoplasty Wasn’t Cosmetic?

The answer to this will depend strongly on your payer’s guidelines, but in general, most insurers want to see documentation of a medical problem that makes the procedure necessary. As most coders already know, Medicare doesn’t cover any cosmetic procedures, so the documentation and diagnosis codes will be essential for showing the insurer that the patient’s procedure was for medical reasons. The following are just a few examples of the dozens of ICD-10 codes cited by insurers as possible diagnosis codes for this service:

  • C44.112: Basal cell carcinoma of skin of right eyelid, including canthus
  • D04.12: Carcinoma in situ of skin of left eyelid, including canthus
  • G51.0: Bell’s palsy
  • H01.004: Unspecified blepharitis, left upper eyelid
  • H02.031: Senile entropion of right upper eyelid
  • H02.231: Paralytic lagophthalmos, right upper eyelid

In addition, there are some conditions that payers may consider cosmetic but may also consider medically necessary depending on the documentation. These include L91.8 (Other hypertrophic disorders of skin) and L98.5 (Mucinosis of the skin), among others. The fact that Medicare payers can go either way with these diagnoses underscores how important it is for the rest of your documentation to clearly show the nature of the medical necessity driving the blepharoplasty.

3. How Do We Differentiate Blepharoplasty From Blepharoptosis?

Blepharoplasty is when the surgeon excises skin and fat and then sutures the skin tighter than it was before so it will no longer droop. Blepharoptosis, however, is a revision of the muscle (for instance, the Muller muscle), typically to correct ptosis. Although confusion between these two conditions is common, the coding is very different, so always take care to confirm blepharitis rather than blepharoptosis before you select a code.

Resource: To read Medicare’s Compliance Newsletter, visit