Effective Oct. 1, 2017, CMS is revising its policy on performing cosmetic blepharoplasty surgery in conjunction with medically necessary ptosis surgery. Per CMS Transmittal 3853, item 5 [PDF], surgeons may receive payment for a medically necessary upper eyelid blepharoptosis from Medicare even when performed in conjunction with a cosmetic, non-covered, blepharoplasty on the same eye during the same surgical encounter. The change applies to services provided Oct. 1, 2017, or later.

Functional Blepharoptosis

• Make sure your documentation covers all requirements and links to the appropriate ICD-10 code(s) provided in your Medicare administrative contractor’s local coverage determination policy.
• Obtain the latest advance beneficiary notice from the Medicare Part B beneficiary for any surgical procedure that could possibly be deemed cosmetic. Be sure to append modifier -GA to 67901-67908.
• Submit all bilateral surgeries as a one-line item with modifier -50 and a “1” in the unit field. Medicare Part B requires this, per the Medically Unlikely Edits published April 2013.

Cosmetic Blepharoplasty

• Medicare does not require you to submit cosmetic surgery, such as blepharoplasty, CPT codes 15822-15823.
• If the patient insists that you file a claim, submit 15822-15823 with modifier -GY.

National Correct Coding Initiative edits continue to have a mutually exclusive bundle with functional blepharoptosis and blepharoplasty procedures. 

Nor does Medicare allow separate payment for the following:

• Operating on the left and right eyes on different days when the standard of care is bilateral eyelid surgery;
• Charging beneficiaries an additional amount for removing orbital fat in conjunction with a blepharoplasty or a blepharoptosis repair.
• Performing a medically necessary blepharoplasty on a different date of service than the blepharoptosis procedure in order to unbundle the medically necessary blepharoplasty;
• Performing blepharoplasty as a staged procedure, either by one or more surgeons (however, under some circumstances, a blepharoptosis procedure could be a staged procedure);
• Billing for two procedures when two surgeons divide the work of a medically necessary blepharoplasty performed with a blepharoptosis repair;
• Using modifier 59 to unbundle a medically necessary blepharoplasty from the ptosis repair on the claim form; this applies to both physicians and facilities;
• Treating medically necessary surgery as cosmetic for the purpose of charging the beneficiary for a cosmetic surgery.

In the rare event that you perform a blepharoplasty on one eye and a blepharoptosis repair on the other eye, you must bill each of the services with the appropriate RT or LT modifier.

Email any additional questions to coding@aao.org.