Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)

CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication, 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI):Medicare NCCI Policy Manual,Chapter 8, Section D. OphthalmologySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34028 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Effective October 1, 2017, The Center for Medicare & Medicaid Services (CMS) revised policy may allow payment to be made for a medically necessary upper eyelid blepharoptosis when performed with (noncovered) cosmetic blepharoplasty on the same eye during the same visit.For correct coding guidelines and specific applicable code combinations prior to billing Medicare, refer to the Medicare NCCI Policy Manual, Chapter 8, Section D. Ophthalmology.Correct coding dictates that removal of malignant and benign lesions requires a different set of codes than the codes listed in this article.Removal of malignant lesions should be reported with CPT codes 11640-11646.Removal of benign lesions should be reported with CPT codes 11440-11446, 67840 or 67850.Mohs surgery should be reported with CPT codes 17311-17315.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The submitted medical recordmust includeresults of pertinent diagnostic tests and operative reportsas appropriate,documentation to support the medical necessity of blepharoptosis repair, brow ptosis repair, and blepharoplasty procedures:Clinical notes, supporting a decrease in visual field (peripheral vision and/or upper field vision) demonstrating a 12 to 15 degree superior loss or 24% to 30% superior visual field impairment, near or far visual impairment, or difficulty reading.Patient complaints and physical findings, for example:Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.Chronic eyelid dermatitis due to redundant eyelid skin.Lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing.Entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation.Difficulty wearing prosthesis.Margin reflex distance (MRD1) of 2 mm or less.A palpebral fissure height on down-gaze of 1 mm or less, (measured with the patient fixating on an object in downgaze with the ipsilateral brow relaxed and the contralateral lid elevated).The presence of Herings Law meeting one of the above criteria in bullets 3 or 4. Herings Law of equal innervation to both upper eyelids may be considered in the documentation to perform bilateral ptosis repair in which the position of one upper eyelid has marginal criteria and the other eyelid had good supportive documentation for ptosis surgery.Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment.Preoperative photographs in the form of prints or slides are required to be submitted with the medical record to support medical necessity of blepharoptosis repair, brow ptosis repair and blepharoplasty procedures if the record is not sufficient to determine medical necessity. If photographs are requested to support the documentation, photograph guidelines that support medical necessity include:The photographs must be frontal view, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin.For CPT codes 15820-15823 or 67901-67908: If redundant skin coexists with true lid ptosis, additional photos taken with the upper lid skin retracted to show the actual position of the true lid margin are supportive of medical necessity.Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.Separate from the photographs, documentation in the medical record of the indicated distance thresholds (e.g., 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that overhangs the eyelid margin [pseudoptosis]) is helpful to demonstrate medical necessity.NOTE:If both a blepharoplasty and a blepharoptosis repair are planned, both must be individually documented. The medical necessity criteria for each procedure must be met and the additional required testing criteria demonstrate visual impairment that cannot be addressed by one procedure alone. This may require two sets of photographs showing the effect of drooping of redundant skin (drooping of brows and its correction by taping), and the actual presence of blepharoptosis with drooping of the upper eyelid.