Article - Blepharoplasty - Medical Policy Article (A52837)

Brow ptosis (performed singly or in combination with other procedures) must be frontal demonstrating:Drooping of brows below the superior orbital rim; and,Improvement of blepharoptosis and/or dermatochalasis by elevation of the brows. (Note: If a blepharoplasty and/or lid ptosis repair and/or brow ptosis are planned, the necessity for each individual procedure performed and billed to Medicare must be documented and supported by photographs. This may require multiple sets of photographs (and/or visual fields), showing the effect of drooping of redundant skin (and its correction by taping or manual retraction) and the actual presence of blepharoptosis and/or brow ptosis and/or an eyelid dermatitis.If the patients only complaint is obstruction of vision when reading, two photographs are obtained to demonstrate the eyelid position in primary gaze (straight ahead) and downgaze (visual axis and camera lens coaxial), demonstrating:The eyelid position in primary gaze (straight ahead) and down gaze (visual axis and camera lens coaxial); and,The subjective complaints of the beneficiary must be well documented in the medical record as well as the medical and/or surgical history supporting eyelid dysfunction. For instance, many patients may not have problems until after fatigue and/or may have more problems in the afternoon compared to the morning.In cases of induction of visually compromising dermatochalasis by ptosis repair in patients having large dehiscence of the levator aponeurosis documentation must demonstrate:Dehiscence of the levator aponeurosis; andAn operative note indicating the skin excess after the ptosis has been repaired and blepharoplasty is necessary.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.The diagnosis code(s) must best describe the patient's condition for which the service was performed.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual,Chapter 30, for complete instructions.Specific coding information for this article:The relevant anatomic modifier or the modifier 59 (distinct procedural services) should be used for procedures at different sites.Appropriate anatomic modifiers for procedure codes 15820-15823 and 67901-67924 are E1 (upper left, eyelid), E2 (lower left, eyelid), E3 (upper right eyelid), and E4 (lower right, eyelid).Brow repair and eyelid procedures performed during the same operative session are subject to multiple surgery guidelines as listed in the Medicare Physician Fee Schedule.When visual fields are done, bill one unit of service per date of service, even if multiple studies are performed.Please see the Documentation Requirements for further instructions for the Part A MAC. The physicians interpretation of the visual fields and the description of the photographic findings may be included in Form Locator 80 of the UB-04 or its electronic equivalent.CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(1)(10) prohibits payment for cosmetic surgery. Procedures performed only to approve appearances without a functional benefit are not covered by Medicare.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 16:20.2.1 Categorical Denials120 Cosmetic Surgery