Blepharoplasty: Medically Necessary Documentation

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 10th, 2016

The following information from one Medicare payer provides guidance on properly coding and documenting blepharoplasty procedures.

Blepharoplasty proceduresandrepairofblepharoptosis are covered when performed for the following functional indications. All other uses would be considered cosmetic.

1. Lower lid blepharoplasty (CPT 15820 and 15821) is considered as medically necessary when documentation:

  • supports horizontal lower eyelid laxity of medial and lateral canthus resulting in dacryostenosis and infection; and/or
  • supports significant lower eyelid edema.
  • reveals that glasses rest upon the lower eyelid tissues and cause lower eyelid ectropion as a result of the weight of the glasses and weight of the tissue.

2. Upper Eyelid Blepharoplasty (CPT 15822 & 15823) is considered medically necessary when:

  • Clinical notes and visual field testing support a decrease in peripheral vision and/or upper field vision; and
  • Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations; and
  • Documentation of visual fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

3. Repair of Brow Ptosis (CPT 67900) and Blepharoptosis (67901 & 67902) are considered medically necessary for the following functional indications:

  • Clinical notes and visual field testing that support a decrease in peripheral vision and/or upper field vision; and
  • Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations; and
  • Documentation of Visual Fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

4. Ptosis Repair (CPT 67903-67908) is considered as medically necessary when:

  • Documentation supports a treatable cause has been excluded; and
  • Pre-operative photos reveal the ptotic lid covering one-forth of the pupil or 1-2mm above the midline of the pupil; and
  • Documentation of Visual Fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

– Surgery: Blepharoplasty (L24814)

References:

Blepharoplasty: Medically Necessary Documentation. (2016, August 10). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/blepharoplasty-medically-necessary-documentation-31592.html

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