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Revised Medicare reimbursement for blepharoplasty spurs changes in practice
Surgeons are now more likely to perform blepharoplasty and blepharoptosis repair at least 3 months apart because of the CMS payment policy.
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A majority of patients objected to paying out of pocket for blepharoplasty or waiting at least 3 months between blepharoptosis repair and blepharoplasty, according to a survey.
Another survey showed that the percentage of oculoplastic surgeons who performed blepharoplasty and blepharoptosis repair at least 3 months apart increased significantly after the Centers for Medicare and Medicaid Services changed the reimbursement policy for blepharoplasty and blepharoptosis repair in 2009.
Investigators at the Mayo Clinic conducted the surveys to gauge patients’ and surgeons’ attitudes and opinions, and changes in clinical practice, stemming from the policy change.
The revised reimbursement policy prohibits separate payments for blepharoplasty and blepharoptosis repair if both are performed on an ipsilateral upper eyelid within a 90-day period. The “bundling” of payments is designed to prevent improper payment for procedures that are considered parts of a more comprehensive process, according to the study authors.
Elizabeth A. Bradley
“I am concerned that the bundling of ptosis and blepharoplasty has created an incentive for ophthalmologists to take care of patients in a way that they don’t want to be taken care of,” Elizabeth A. Bradley, MD, the corresponding author, said in an interview with Ocular Surgery News. “The physician only gets reimbursed for doing one of the two procedures, even if the procedures are done using two separate incisions. A blepharoplasty is always done from an external approach. But ptosis repair is often done from an internal approach, so the surgeon is making a completely different incision operating on a completely different anatomic structure.”
“[Surgeons] don’t want to assume the surgical risk of doing two distinct procedures without compensation for one of the procedures, and that’s what’s happening,” she said. “This is an example where bundling doesn’t work well because it sets up this conflict.”
Impact on surgeons and patients
Bradley said that following the change in Medicare policy, many surgeons will do blepharoplasty and blepharoptosis repair in two separate operative sessions.
“That’s undesirable to most patients,” she said. “On the other hand, patients aren’t willing to pay very much out of pocket for having the surgeries done together, with the blepharoplasty, for example, being considered cosmetic.”
The policy change significantly reduces surgeons’ revenues for eyelid surgery, Bradley said.
The survey results were published in a study online ahead of print in Ophthalmology.
Survey design and results
The cross-sectional study included 50 patients with visually significant ptosis and dermatochalasis who were eligible for unilateral or bilateral blepharoplasty and ptosis repair and 190 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery.
A five-question paper survey was sent to patients, and a separate five-question Web-based survey was sent to 510 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery.
Results showed that 91% of patients were adverse to paying out of pocket for blepharoplasty or waiting at least 3 months between blepharoptosis repair and blepharoplasty. When given a choice between those options, 62% of patients indicated a preference for undergoing the two procedures separately as opposed to paying out of pocket.
Nine patients (18%) were willing to pay more than $500 out of pocket for eyelid surgery, 28 patients (56%) were unwilling to pay out of pocket or would pay between $1 and $500, 12 patients (24%) were unsure about how much they would pay, and one patient did not answer the question.
Before the policy change, 77% of oculoplastic surgeons performed blepharoplasty and blepharoptosis repair at the same time, compared with 37% after the change (P < .001).
Four percent of surgeons performed the two procedures at least 3 months apart before the policy change and 29% performed the two procedures at least 3 months apart after the change (P < .001).
Five percent of surgeons billed patients for a cosmetic blepharoplasty before the policy change, compared with 12% after the change (P = .009).
“A surgeon could make the argument that the ptosis is what’s significant. That’s what he is going to correct and get reimbursed for by Medicare,” Bradley said. “That will result in some bunching of the skin, and the patient might not be happy with the cosmetic appearance. The functional deficit will be improved by the ptosis surgery. So, some physicians will then ask a patient to pay for the blepharoplasty as a cosmetic procedure. It gets very complex because there are Medicare rules that you can’t ask a patient to pay out of pocket for what would be a covered Medicare service. So, only by deeming it cosmetic can you ask a patient to pay out of pocket.” – by Matt Hasson
Reference:
Bajric J, et al. Ophthalmology. 2014;doi:10.1016/j.ophtha.2014.01.005.For more information:
Elizabeth A. Bradley, MD, can be reached at Mayo Clinic Department of Ophthalmology, 2001 1st St. SW, Rochester, MN 55905; 507-284-2511; email: bradley.elizabeth@mayo.edu.Disclosure: Bradley has no relevant financial disclosures.