Properly documenting functional blepharoplasty surgery

Documenting the medical necessity for this procedure is difficult.

Issue: December 1, 2003

ByE. Ann Rose

Issue

A patient presents to the office complaining of inability to see low-lying tree limbs while out walking, and also having to raise eyelids manually when trying to read street signs. Upon examination, the patient’s visual acuity is 20/20 with eyelids raised by the examiner. The physician observes that the patient’s lids cover two-thirds of the pupil in the left eye and half the pupil in the right eye. The patient’s lid crease measures 13 mm and the lid fissure measures 12 mm. The patient also demonstrates severe dermatochalasis by measurement and external photos.

The physician orders a visual field with the eyelids in repose, as well as in a taped position. A report documents that the patient has severe upper field loss that is corrected upon taping the eyelids. The physician discusses the findings with the patient and recommends bilateral ptosis repair with removal of the excess skin.

Has the chart been properly documented to substantiate billing Medicare for a functional repair of the eyelid?

Documenting the medical necessity of lid surgery, mainly blepharoplasty for the repair of blepharochalasis or dermatochalasis, is extremely difficult. Medicare and other third-party payers generally take the position that the excision of excess skin is cosmetic. While it may be apparent to the physician that the procedure will provide an improvement of the patient’s visual difficulty, payors must be able to follow the physician’s thought process on paper in the event of an audit.

To develop the necessary documentation, physicians must record, in detail, the patient’s lifestyle problems with the “droopy lid.” As with all patient complaints, this should be documented in the patient’s own words and in quotes. In addition, the record should include preoperative photographs (at least two copies). Most Medicare carriers no longer require the photographs to be submitted in advance with the claim, but physicians must have a second set available in the event Medicare develops the claim for additional information. Always obtain preop visual fields (ie, tangent screen, 78-point screen or 80-point screen) with the lid taped up and with the lid in normal position. Because this results in two isopter fields, the maximum billable level of visual fields would be code 92082, intermediate visual field.

The external photos and the visual fields are required for medical necessity and are reimbursable by Medicare. Physicians should resist any attempt by the payor to deny the external photos; appeal the denials because the photos are a carrier requirement and not a routine part of the exam.

It is also important to understand that medical necessity will not be supported by the documentation of the patient’s visual acuity without the lid problem. If the patient is 20/20 without any significant visual field loss documented in the chart, the question to be considered is whether the procedure is cosmetic or functional. If this procedure can help the patient functionally, then proceed after you have documented the medical necessity, medical justification and medical reasonableness of the procedure in the patient’s chart.