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Document medical necessity and save $500 per procedure Blepharoplasty and ptosis repair can be lucrative procedures - if you can meet requirements like keeping visual field data in the patient's records and appending the proper modifiers for bilateral procedures. Take a look at the experts' answers to your most frequently asked questions about these repair procedures. How can we prove that the ptosis repair is medically necessary? Because brow ptosis repair and blepharoplasty can be done for cosmetic reasons many insurers automatically assume that CPT codes 67900-67908 are not medically necessary. You need to document that the ptosis excess fat or excess tissue is impairing the patient's vision says Debby Campbell CPC coding specialist for Slingsby & Wright Eye Care in Rapid City S.D. \"We do visual fields \" Campbell says \"and we always have pictures\" in the medical record. The ophthalmologist does the visual fields test twice Campbell says - once normally and once with the extra fat or tissue taped out of the way of the patient's eyes to simulate surgery results. Tip: Most local medical review policies (LMRP) require a 12 to 30 percent improvement between untaped and taped visual fields. LMRPs may vary in what they want photos to show but CIGNA Healthcare's policy is typical. \"Photographs should demonstrate one or more of the following \" CIGNA says: - The upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex.
- The upper eyelid skin rests on the eyelashes.
- The upper eyelid indicates the presence of dermatitis.
- The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.
The good news: You don't have to submit all of these things to get reimbursed. Many offices typically ask for preauthorization from the carrier but usually \"nothing needs to be sent in to get preauthorization \" says Regan Bode CPC clinic administrator at the Northwest Eye Clinic in Lynden Wash. You just have to have documentation on file in case your bleph claims are ever audited she says. Carriers will mainly look at the diagnosis to make sure it establishes medical necessity. In the event of an audit she says \"you would just need to be able to show them the fields and the photos - your documentation that it was impairing their vision.\" Note: For a list of ICD-9 codes that commonly support medical necessity for blepharoplasty and brow repair see \"Show Medical Necessity for Ptosis Repair\". Can we bill twice for the taped and untaped visual fields? "You can only bill for it once \" Bode says. But you can report a code that includes the work of drawing two isopters (the graphic representation of the patient's field of vision). Use 92082 (Visual field examination unilateral or bilateral with interpretation and report; intermediate examination [e.g. at least 2 isopters on Goldmann perimeter or semiquantitative automated suprathreshold screening program Humphrey suprathreshold automatic diagnostic test Octopus program 33]) Bode says. Another way: "Since the insurance company mandates this testing and it requires additional work and resources it should be billed and reimbursed by the insurance carrier \" says Maggie M. Mac CMM CPC CMSCS consulting manager for Pershing Yoakley & Associates in Clearwater Fla. \"Documentation should show a report and findings for each test separately documented.\" Append modifier -76 (Repeat procedure by same physician) to the second test Mac says. "Some payers may require an explanation for the billing of the second test before reimbursing for both tests \" she says. \"LMRPs may differ in their approach to billing the two tests so it's a good idea to check with your local carrier for assistance with this billing.\" What if the doctor does a bilateral brow lift - should we code bilaterally or unilaterally? The brow area is not naturally broken into two parts so coding 67900 (Repair of brow ptosis [superciliary mid-forehead or coronal approach]) bilaterally can be tricky. Appending modifier -50 (Bilateral procedure) is out because 67900 has a bilateral surgery indicator of \"0\" (the 150 percent payment adjustment for a bilateral procedure does not apply) in the Medicare Physician Fee Schedule Relative Value Database. For a bilateral brow lift Campbell says report code 67900 on two lines with -RT and -LT modifiers to indicate that the procedure was done on both sides. What's the difference between 67901-67908 and 15820-15823? Both code sets address the same problem - reduced fields of vision due to eyelid obstruction. However they represent two different underlying causes and two different solutions to the problem Bode says. Blepharoplasty - represented by CPT codes 15820 -15823 - is an excision of skin and fat. The repair codes 67901-67908 represent a revision in the actual muscle for example 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement external approach) in which the ophthalmologist shortens the levator tendon until the lid is at the proper level. What's the difference between the blepharoplasty and blepharoptosis repair codes and the ectropion and entropion repair codes? Unlike blepharoptosis and brow ptosis which can be cosmetic problems only entropion and ectropion are by definition medical problems says Nancy Swancutt CPC surgery coordinator in the department of ophthalmology at the University of Virginia Medical Center in Charlottesville. If the patient has ectropion the lower lid droops so much that it turns away from the eyeball resulting in potential damage from exposure. With entropion the lower lid turns inward also creating a risk of damage. An ectropion repair code (67914-67917) tells the payer that the procedure is for an ectropion not for a lower-lid ptosis that may be unattractive but doesn't pose a danger to the eye. Use ectropion (374.1x) as the primary diagnosis with the problem caused by the ectropion such as exposure keratitis (370.34) as the secondary diagnosis. Be specific: Blepharoplasty codes are eyelid-specific but entropion and ectropion repair codes are not. For example compare the descriptor for 67914 (Repair of ectropion; suture) with the descriptor for 15820 (Blepharoplasty lower eyelid). Note that the blepharoplasty code specifies which lid upper or lower the procedure corrects. Do this: You should use -LT and -RT modifiers with the blepharoplasty codes Swancutt says. For your Medicare carrier you may need to use the eyelid modifiers such as -E1 on the entropion and ectropion repair codes. For example you would bill a repair of an entropion on the upper-right lid using tarsal wedge excision as 67923-E3. Other insurance companies may not recognize the E1-E4 modifiers but will accept -RT or -LT. What are the NCCI bundles? Since 2000 NCCI has bundled 15820 (Blepharoplasty lower eyelid) and 15822 (Blepharoplasty upper eyelid) into blepharoptosis repair codes 67901 (Repair of blepharoptosis; frontalis muscle technique with suture or other material) 67902 (... frontalis muscle technique with fascial sling) 67903 (... [tarso] levator resection or advancement internal approach) 67904 67906 (... superior rectus technique with fascial sling) and 67908 (... conjunctivo-tarso-Muller's muscle-levator resection). If the ophthalmologist performs both blepharoplasty and blepharoptosis repair at the same session you can break the bundle by appending modifier -59 (Distinct procedural service) to the blepharoplasty procedure.
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ophthalmology codes, cpt codes 67900-67908, ptosis repair coding, medical coding, medical billing, medical coding & billing, medical coding articles,
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