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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 (CPT15822 & 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).
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