Article - Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift (A56908)

CMS National Coverage PolicyTitle XVIII of the social Security Act section 1833 (e). This section prohibits Medicare Payment for any claim that lacks the necessary information to process the claim.Title XVIII 0f the Social Security Act section 1862 (a)(10). This section excludes cosmetic surgery, except as required to repair an accidental injury or for the improvement of the function of a malformed body member.CR 10236  October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS), 5. Upper Eyelid Blepharoplasty and Blepharoptosis Repair.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD.List the appropriate CPT code for the procedure performed; include any appropriate modifiers.Physicians services and diagnostic tests must be submitted with a diagnosis code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise diagnosis code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the digit sub-classification for the diagnosis category. The diagnosis code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the diagnosis code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury resulting in a functional anomaly of the upper eyelids a cosmetic diagnosis should be reported, and payment will be denied.The Medicare global surgery and CCI rules apply to these eyelid surgeries.If bilateral reconstruction is done on the same day, report one line of service using the 50 modifier or report two lines of service with the RT and LT modifiers.If a patient wishes to have a blepharoplasty or brow lift for cosmetic purposes:The physician should explain to the patient, in advance, that Medicare will not cover cosmetic eyelid or brow surgery and that the beneficiary will be liable for the cost of the service. Charges should be clearly stated. A claim for cosmetic services does not need to be submitted to the Medicare contractor, unless the patient requests that the claim be submitted on his/her behalf.When the patient requests the claim for cosmetic services be submitted on his/her behalf, the services should be reported with modifier GY (items or services statutorily excluded or does not meet the definition of any Medicare benefit)anddiagnosis code Z41.1. The diagnosis code Z41.1 should be placed in the first position in item 21 on the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims. A Notice of Exclusion from Medicare Benefits (NEMB) may be used with services excluded from Medicare benefits.When the signs or symptoms are present (See L34528 Coverage Indications, Limitations and/or Medical Necessity) physicians are encouraged to place the appropriate diagnosis code in the first position with the available symptom diagnosis code in the second position in item 21 of the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims.Visual Field exams are classified as bilateral procedures where the bilateral adjustment does not apply; the Physician Fee Schedule amount represents payment forbotheyes. The procedure should be reported on a single claim linewithoutthe 50 or RT/LT modifiers. In the event that the procedure is performed on only one eye per DOS the procedure may be reported with a 52 modifier  (reduced service) and a reduced charge.Photographs are not separately billable to Medicare.The following situation will result in the denial of initially billed Blepharoplasty, Blepharoptosis or Brow Lift services or in some cases as a result of a post payment review.Physicians services submitted without a diagnosis code or not coded to the highest level of accuracy and digit level completeness will be denied as unprocessable.When blepharoplasty is performed to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure is considered cosmetic and not covered by Medicare. (Use the GY modifier and ICD-10 code Z41.1 for a non-covered denial.)