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Elizabeth Posted 7 Year(s) ago

This is a surgery that i would like to enter but the correct why. would it be 67904 59 lt and 67904 59 rt and 15823 59 rt and 15823 59 lt for payment to medicare. thank you for your help.

SuperCoder Posted 7 Year(s) ago

Avoiding Denials from Coding point of view:-
Correct Coding Initiative (CCI) made 15823 and 67904 mutually exclusive, meaning Medicare believes that the two procedures would not typically be performed at the same operative session. In other words, an ophthalmologist would either perform blepharoptosis repair or blepharoplasty, not both.

The pair has a modifier indicator of 1. So, if the ophthalmologist performs the blepharoplasty (bleph) with excessive weight (15823, Blepharoplasty, upper eyelid; with excessive skin weighting down lid) on one eye and the blepharoptosis (ptosis) repair (67904, Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) on the other eye, you may be able to report both codes by using modifier 59 (Distinct procedural service) on 15823 to designate a separate site from 67904. Otherwise, you should report only 67904.

CPT code 15823 is typically submitted for functional claims. One key component often missing in chart documentation for functional claims is the lack of a visual complaint from the patient. Too often the chart might state, “Patient complains of excessive baggy upper lid skin,” which does not provide medical justification for a functional claim.

Don't Overlook Eyelid Modifiers:-
Occasionally, the eyelid modifiers (-E1-E4) are preferable to modifiers -RT and -LT. For example, the ophthalmologist performs 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) on both upper lids.

When performed bilaterally, you should use 67904-50 for Medicare, not the eye modifiers or the eyelid modifiers.

But for other payers, you should use the eyelid modifiers - for example, 67904-E1 and 67904-E3 for both upper lids. The eyelid modifiers are more specific than either 67904-50 or 67904-RT and 67904-LT.

Major Reasons for Denial:-
Lack of supporting documentation in the medical record to reflect the medical necessity for the performance of the procedure will result in denial of the service.

Blepharoplasty is considered cosmetic and non-covered under the Medicare program when performed to improve appearance in the absence of any signs and/or symptoms of functional abnormalities except when required for the repair of accidental injury or for the improvement of the functioning of a malformed body member. (Social Security Act §1862 (a)(10))

Lower lid blepharoplasty is generally not reimbursable, since it is usually performed for cosmetic purposes.

General conditions of Coverage:-
Authorization, Precertification (mostly required for inpatient admission), Precertification with MD Review,

Site(s) of Service is generally Office, Outpatient and if not listed, MD Review required.

Required Documentation for Clinical Review:-
•Letter of medical necessity and/or clinical office notes >Visual fields
Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated (e.g., taped or manually retracted) to demonstrate an expected "surgical" improvement meeting or exceeding the criteria.
•Medical photographs
Photographs (prints, not slides) must be frontal and canthus-to-canthus with the head perpendicular to the plane of the camera (i.e., not tilted) in order to demonstrate the position of the true lid margin or the "false lid margin" in the case of pseudoptosis caused by severe dermatochalsis. The photographs must be of sufficient clarity to show a light reflex on the cornea or the relationship of the eyelid to the cornea or pupil (except in cases where the lid margin obscures the corneal light reflex or a digital camera is used and there is no light reflex).

Posted by Elizabeth, 7 Year(s). There are 2 posts. The latest reply is from SuperCoder.

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