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Article -- Coding Guidelines

Contractor Name
HealthNow

Contractor Number
00801

Contractor Type
Carrier

Article Database ID Number
A46188

Contractor Determination Number
SU035E00

Article Type
Article

Article Title
Blepharoplasty -1

Is the AMA CPT / ADA CDT Copyright Statement Required?

CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other data of publication of CPT). All Rights Reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. (C) 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction
Upstate New York

Original Article Effective Date
07/20/2007

Article Revision Effective Date
07/20/2007

Article Ending Effective Date

Article Text
The information in this article contains coding or other guidelines that complement the Local Coverage Determination (LCD): Blepharoplasty (R3). This LCD can be accessed on our contractor web site at www.empiremedicare.com. It can also be found on the Medicare Coverage Database located at www.cms.hhs.gov/mcd.

Coding Guidelines

   1.  The guidelines of the Correct Coding Initiative (CCI) supersede all
       coding instructions in this LCD. For a complete listing of CCI coding
       combinations, refer to CMS' website,
       http://www.cms.hhs.gov/NationalCorrectCodInitEd

   2.  The diagnosis code(s) must best describe the patient's condition for
       which the service was performed.

   3.  Billed services for which the provider expects a medical necessity
       denial should have either the GA (with signed ABN) or GZ (without
       signed ABN) modifier attached to the code. If the service is
       statutorily non-covered or without benefit category, use the GY
       modifier instead.

   4.  Appropriate anatomic modifiers are E1 (upper left, eyelid), E2 (lower
       left, eyelid), E3 (upper right eyelid), and E4 (lower right, eyelid).

   5.  Brow repair and eyelid procedures performed during the same operative
       session are subject to multiple surgery guidelines as listed in the
       Medicare Physician Fee Schedule.

   6.  If the beneficiary wishes to have a procedure for cosmetic purposes,
       the beneficiary becomes liable for the service rendered. A claim for a
       cosmetic procedure should not be submitted to Medicare except by
       patient request,or for denial purposes.

       a.   Since cosmetic surgery is a program exclusion, a Medicare advance
            beneficiary notice (ABN, Form CMS-R-131) should not be used.
            However, it is recommended that the physician notify the patient
            in advance that Medicare will not cover cosmetic surgery and that
            the beneficiary will be liable for the cost of the service. It is
            suggested that the beneficiary be provided with a written
            notification of this fact and that the beneficiary, by his/her
            signature, accepts responsibility for payment. A "Notice of
            Exclusion for Medicare Benefits" should be issued to
            beneficiaries in order to make clear the non-covered aspects of
            cosmetic surgery. This notice may be found at:
            http://cms.hhs.gov/medicare/bni/20007 English.pdf.

       b.   The ICD-9-CM code that should be filed in this situation is
            ICD-9-CM codes V50.1 "Elective surgery for purposes other than
            remedying health states, other plastic surgery for unacceptable
            cosmetic appearance". The CPT code indicating what procedure was
            performed should have modifier GY, "Item or service statutorily
            excluded or does not meet the definition of any Medicare
            benefit." Using the GY modifier will result in denial of
            Medicare payment for the service.

   7.  Apropriate places of service for the CPT codes listed in this policy
       are: office (11), inpatient hospital (21), outpatient hospital (22)
       ambulatory surgical center (24) and independent clinic (49). Note that
       for CPT codes 67915 and 67922, only the physician's fee will be
       allowed when these services are performed in the ambulatory surgical
       center (24).

Coverage Topic
Surgical Services

CPT/HCPCS Codes
The CPT codes in Group 1 are generally always considered reconstructive in nature.

67909 REDUCTION OF OVERCORRECTION OF PTOSIS

67911 CORRECTION OF LID RETRACTION

67914 REPAIR OF ECTROPION; SUTURE

67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION

67916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE

67917 REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)

67921 REPAIR OF ENTROPION; SUTURE

67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION

67923 REPAIR OF ENTROPION; EXCISION TARSAL WEDGE

67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)

The CPT codes in Group 2 may be considered as cosmetic and thus not covered by Medicare unless the claims are accompanied by appropriate documentation to support functional impairment, visual or otherwise. (Please see the "Indications and Limitations" and "Documentation Requirements" sections.)

15820 BLEPHAROPLASTY, LOWER EYELID;

15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD

15822 BLEPHAROPLASTY, UPPER EYELID;

15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID

67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)

67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)

67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)

67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH

67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH

67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA)

67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)

Other Comments
For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier should provide the patient with an acceptable advance notice of Medicare's possible denial of payment. An advance beneficiary notice (ABN) should be signed when a provider/supplier does not want to accept financial responsibility for the service.

Revision History
Revision #1: Effective for dates of service on and after 07/20/2007, place of service was expanded to include office and independent clinic.

Does this Article contain a "Least Costly Alternative" provision?
No

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