BLOG: Beware of Medicare audit for ptosis and pseudoptosis procedures

Recently, I was speaking with a comprehensive ophthalmology colleague who had just performed a pseudoptosis (blepharoplasty) procedure. I asked him if he knew about the Medicare audits, and he said he had no idea what I was talking about. He showed me his records, and based upon what I saw, if he were audited, the procedure would be denied and he would not get paid for the procedure. Or, if he were paid, he would have to send the payment back.

Moreover, the surgery center where we operate would likewise be denied, and therefore the final summation would be that the patient had a free surgery, and the surgeon and facility would be out reimbursement. The patient would have no responsibility for payment to the physician or the surgery center.

Because Medicare does not require predetermination, it is important that those of us who are doing pseudoptosis and ptosis procedures be vigilant in our documentation. Presently, Medicare asks for three things:

1. A valid chief complaint

2. Excellent photographs

3. Visual fields taped and un-taped

The valid chief complaint needs to state, “I have to raise my eyebrows to get my lids to the point where I can see traffic lights or have better peripheral vision,” or “When I read, I find I have to hold my upper lid up to see,” or something similar to that. The patient stating that “I have heavy lids” or “My doctor sent me to have this” is not good enough.

Two pictures should be taken: a frontal view showing the marginal light reflex distance is 2.5 mm or less, and a side view showing the extra skin onto the lashes, giving a lash ptosis and a visual field deficit.

The visual field should show visual field impairment of a minimum of 12°, or 30% loss of upper field of vision improved on taping the eyelids.

Failure to meet any one of the three criteria will most probably result in a denial. The appeals process can be problematic and time-consuming. Therefore, it becomes a judgment call. For example, in the case of a pseudoptosis with some skin encroaching onto the lashes, you need to decide whether it is worth your while to proceed with the surgery or just tell the patient, “I do not feel Medicare will cover this, and it will have to be a self-pay.”

Another option is have the patient sign a form stating that if Medicare denies the claim, the patient will be responsible for the surgeon’s fee, anesthesia and facility charge according to the Medicare rates. None of us want to do surgery for nothing, although sometimes in financial hardship cases, I am willing to take my chances, document really well, and chalk it up to doing a good deed for somebody who really needs it.

I would like to tell you this is just a local problem in Cleveland, but it is a national problem that will hopefully be clarified in the near future with help from our national, state and local societies.

So how did all this happen so suddenly? Michael Migliori, MD, president of the American Society of Ophthalmic Plastic and Reconstructive Surgery, recently made these remarks in a letter to our membership: “In May, The Center for Public Integrity (CPI) published an article titled ‘Eyelid lifts skyrocket among Medicare patients, costing taxpayers millions.’ In that article, the authors stated that the number of blepharoplasties charged to Medicare more than tripled between 2001 and 2011, and charges to Medicare rose from $20 million to $80 million, while the number of physicians billing for that surgery doubled. They cited one surgeon in Florida billed Medicare $800,000 for 2,200 blepharoplasties in 2008 alone. The obvious conclusion is physicians gaming the system.”