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Practice Management Express Spotlight — August 18, 2013

Cosmetic vs. Functional Blepharoplasties: Does Your Documentation Support the Difference?

[PDF 291K]
Blepharoplasty is the number one Recovery Audit Contractor (RAC) audit currently reported.
Previous Focused Medical Review audits help explain why CPT code 15823 Blepharoplasty, upper eyelid; with excessive skin weighing down lid is vulnerable to audit.

Audit Vulnerabilities and Triggers

There are usually three problems in documentation and claim submission: inadequate and/or cloned chief complaint, lack of awareness of payer documentation requirements and use of modifier –GY.

Chief complaint
Even if other supporting documentation shows that the procedure was not cosmetic, the history needs to describe the functional impairment.

  • Cosmetic chief complaint: “Patient unhappy with appearance due to baggy upper eyelids”
  • Functional impairment chief complaint: “Upper lids so heavy, patient has to hold lids up to see well.”

Cloned complaints
You also need to provide a patient-specific complaint. Reusing the same wording verbatim on multiple chart notes commonly fails audits, as it can appear that the patient’s history isn’t unique to the patient.

  • Example of a cloned note on several patients: “The patient presents for evaluation of droopy eyelids OU. It started about three years ago. Onset is progressive, condition is worsening.”

Use of modifier —GY
Claims submitted with modifier –GY are another audit trigger. The Office of the Inspector General (OIG) Work Plan says that historically Medicare received more than 75 million claims with modifier –GY, totaling roughly $820 million. Consequently, the OIG scrutinizes physicians’ and suppliers’ use of modifier -GY.

If your practice has added modifier –GY in cases where the procedure is cosmetic, you have two options that comply with the rules. One is to not submit the procedure at all. The other, if you want to track cosmetic blephs internally, is to use CPT code 15822-50 Blepharoplasty, upper eyelid.

Bilateral blephs
Functional blephs should be submitted with CPT code 15823-50-GA.

  • For bilateral surgeries, use modifier -50 and submit the procedure as a single line item (per the Medically Unlikely Edits that took effect April 1). Place a “1” in the unit field.
  • Claims submitted as a two-line item with modifiers –RT and –LT will be denied.

Use modifier –GA to indicate you have an Advance Beneficiary Notice (ABN) on file. In most cases you should obtain an ABN from the patient in case the payer determines documentation doesn’t support functional requirements.

General Guidelines

Definitions for a functional blepharoplasty can vary by payer. You should review your carriers’ Local Coverage Determination Policy (LCD) to ensure you’re coding according to the definition. The Coding Tools page on AAOE’s website will direct you to the Medicare Coverage Database to view these polices. Most LCD documentation requirements include:

  • Documentation of visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis;
  • Documentation of symptomatic redundant skin weighing down on upper lashes;
  • Documentation of chronic symptomatic dermatitis of pretarsal skin caused by redundant upper-lid skin; and/or
  • Prosthesis difficulties in an ophthalmic socket.

These policies often require photographs and visual field tests to prove the medical necessity requirements of ptosis, pseudoptosis, or dermatochalasis. The evidence should show problems like difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin or chronic blepharitis.

Jennifer Arbuckle, OCS, CPC AAOE —Academy Coding Specialist

Sue Vicchrilli, COT, OCS —Academy Coding Executive