When blepharoplasty is performed to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure is considered cosmetic and not covered by Medicare. (Use the GY modifier and ICD-10 code Z41.1 for a non-covered denial.) Coding Information
Full Answer
What is the ICD 10 code for blepharoplasty?
In addition, for the Group 2 ICD-10-CM codes and Group 2 CPT codes listed in the A56439 Billing and Coding Article Blepharoplasty, documentation should consist of visual field results and/or photographs. b.An operative note indicating the skin excess after the ptosis has been repaired and blepharoplasty is necessary.
Does the proposed LCD provide coverage for upper and lower blepharoplasty?
The proposed LCD and related Billing and Coding Article will provide limited coverage for upper and lower blepharoplasty as well as repair of brow ptosis when performed for functional indications. An asterisk ( *) indicates a required field.
What are the indications for upper blepharoplasty?
Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients with an anophthalmic socket experiencing ptosis or prosthesis difficulties.
Does Medicare cover eyelid surgery?
If the eyelid surgery is for cosmetic purposes, Medicare recipients do not have coverage. Under Original Medicare Part B, you are responsible for your yearly deductible of $185 (in 2019) and coinsurance payments.
How do you code a blepharoplasty?
Blepharoplasty of the lower lid (CPT codes 15820, 15821) is generally considered cosmetic and will be denied as non-covered....Group 1.CodeDescription15820BLEPHAROPLASTY, LOWER EYELID;15821BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD15822BLEPHAROPLASTY, UPPER EYELID;8 more rows
Does Medicare cover blepharoplasty eyelid surgery and brow lift?
Medicare does not offer coverage for cosmetic surgery. But the program does pay for eyelid lifts, known as blepharoplasty, when a patient's sagging eyelids hinder their vision. Medicare reimbursement for eyelid surgery ranges from $574 to $640 per eye—not exactly a big ticket item.
Can blepharoplasty be medically necessary?
Typically, an upper-eyelid blepharoplasty can be considered medically necessary when the upper-eyelid skin is drooping down to the extent that it is blocking vision, usually within the superior visual fields.
Is blepharoplasty a NCD policy?
Blepharoplasty (Lower Lid) (CPT codes 15820 and 15821) Medicare does not have a National Coverage Determination (NCD) for lower lid blepharoplasty.
What is the criteria for eyelid surgery?
Blepharoplasty may be an option if you have: Baggy or droopy upper eyelids. Excess skin of the upper eyelids that interferes with your peripheral vision. Excess skin on the lower eyelids.
Is an eyebrow lift covered by Medicare?
Answer: Medicare coverage Generally Medicare will not cover an eyebrow lift, but may cover an eyelid lift if you are evaluated by an optometrist or ophthalmologist and you fail a peripheral visual field test that they administer.
Is blepharoplasty covered by insurance?
If the reason for the eyelid surgery is medical or functional, then sometimes the insurance company will pay for upper eyelid blepharoplasty or ptosis surgery. Medical or technical interference with vision is when the eyelids start to cover the visual axis or interfere with the top field of view.
Is blepharoplasty considered cosmetic surgery?
For the most part, the blepharoplasty is considered an optional cosmetic procedure. However, if you are able to take a visual field exam with your ophthalmologist that clearly demonstrates the eyelids as the cause of vision impairment, it can be deemed medically necessary.
Is droopy eyelid surgery necessary?
For some, eyelid surgery is a medical necessity, especially if the excess skin hangs down far enough over the upper lid that it blocks vision. At this point, most insurance companies will pay for the procedure to restore lost vision. Here are some of the most common medical reasons this surgery is performed.
What is the CPT code for blepharoplasty of the left lower eyelid?
Lower eyelid blepharoplasty (CPT 15820, 15821) Lower eyelid blepharoplasty to remove excess skin, fatty tissue, or both, is considered not medically necessary in the absence of the medical condition of ectropion, entropion, or other functional visual impairment.
Can 15823 and 67904 be billed together?
The bundles for CPT codes 15823 (blepharoplasty) and 67904 (external levator resection) should not be broken unless one of the procedures (ie, blepharoplasty repair) is being done on one side and the second procedure (ie, ptosis repair) is being performed on the contralateral side. This would be most unlikely.
What is excess eyelid skin called?
Most commonly found in patients over 50 years of age, dermatochalasis is a condition involving excess skin of the upper and lower eyelid.
General Information
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33944-Blepharoplasty.
ICD-10-CM Codes that Support Medical Necessity
It is the responsibility of the physician/provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.
Coverage Guidance
Abstract: Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery.
General Information
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the social Security Act section 1833 (e). This section prohibits Medicare Payment for any claim that lacks the necessary information to process the claim.
Article Guidance
The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD.
ICD-10-CM Codes that Support Medical Necessity
List the diagnosis code that best describes the patient’s condition. Diagnosis codes must be present on all physician’s service claims and must be coded to the highest level of accuracy and digit level completeness.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act section 1862 (a) (10). This section excludes cosmetic surgery, except as required to repair an accidental injury or for improvement of the function of a malformed body member.
Coverage Guidance
Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either functional/reconstructive or cosmetic.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, §1862 (a) (1) (A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Article Guidance
The following coding and billing guidance is to be used with its associated Local coverage determination.
ICD-10-CM Codes that Support Medical Necessity
It is the responsibility of the physician/provider to code to the highest level specified in the ICD-10-CM (e.g., to the third or seventh character). The correct use of an ICD-10-CM code listed below does not assure coverage of a service.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
How much is blepharoplasty deductible?
Under Original Medicare Part B, you are responsible for your yearly deductible of $185 (in 2019) and coinsurance payments. Under Medicare Advantage, the benefits and costs of medically necessary blepharoplasty depend on your individual insurance plan, so carefully review your policy for the details. It is difficult to determine what your final cost ...
How long does it take for a blepharoplasty to heal?
Full recovery from blepharoplasty usually takes several weeks, but stiches come out after 2-7 days. Redness and swelling are common after surgery and patients should let their eyes rest well during recovery.
Is blepharoplasty covered by Medicare?
If your eyelid surgery is medically necessary to improve function or ability, it is considered reconstructive surgery. Because blepharoplasty is generally an outpatient procedure, it may be covered by Original Medicare Part B (Medical Insurance), or Medicare Advantage (Part C).
Is blepharoplasty a cosmetic procedure?
Blepharoplasty is one of the top five plastic surgical procedures performed in the United States for both men and women, and it is becoming more and more common every year. Many people have eyelid surgery for cosmetic reasons, but it is more commonly done for reconstructive or functional reasons.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, §1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Article Guidance
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Blepharoplasty, Eyelid Surgery, and Brow Lift L34411.
ICD-10-CM Codes that Support Medical Necessity
It is the responsibility of the physician/provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10 code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.