SEP 05, 2017
How to Bill for Upper Eyelid Blepharoplasty and Blepharoptosis Repair
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.
- 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.
- 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 firstname.lastname@example.org.