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CMS alters guidelines for combined blepharoplasty and ptosis surgery
The new policy allows surgeons to bill patients for a cosmetic blepharoplasty performed at the same time as functional ptosis surgery.
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CMS has revised the July 2016 policy for same-day, same-eyelid blepharoplasty and ptosis surgery.
The new policy, which went into effect Oct. 1, 2017, allows surgeons to bill patients for a cosmetic blepharoplasty surgery if it is performed on the same eyelid and on the same day as functional or medically necessary ptosis surgery. Long-standing Medicare National Correct Coding Initiative (NCCI) edits bundle upper lid blepharoplasty (CPT 15823) and ptosis surgery (CPT 67901, 67902 and 67904); those edits remain in effect but only apply to medically necessary, covered procedures. The July 2016 policy did not make a distinction between cosmetic and functional blepharoplasty and did not allow surgeons to bill patients for cosmetic surgery, according to Kevin J. Corcoran, COE, CPC, CPMA, FNAO, OSN Practice Management Board Member.
“In the earlier rule, any blepharoplasty was considered to be integral or incidental to the ptosis repair,” Corcoran said.
The change
According to a summary published by Corcoran Consulting Group, if both eyelid procedures are medically necessary and functional, then NCCI bundles apply and only the ptosis repair is billed. However, if the ptosis repair is functional and the associated blepharoplasty is cosmetic, the surgeon may bill the patient for the blepharoplasty and Medicare for the ptosis repair.
The community of oculoplastic surgeons took exception to the earlier rule on the grounds that CMS has no authority to bundle a noncovered, cosmetic procedure with a covered, medically necessary procedure, he said.
“As a result, the new rule says if you perform a cosmetic blepharoplasty and a functional or medically necessary ptosis surgery at the same time, the cosmetic blepharoplasty is independently paid to the surgeon by the patient. That’s a change because whether it was functional or cosmetic in the July 2016 rule, it didn’t make any difference. The rule says that if the blepharoplasty is functional, then nothing changes; it still remains the case that a functional blepharoplasty and a functional ptosis procedure performed at the same time, then you only bill one procedure, in this case the ptosis procedure,” Corcoran said.
Surgeon perspective
OSN Oculoplastic and Reconstructive Surgery Section Editor Wendy W. Lee, MD, said the revision to the 2016 rule by CMS is welcomed by oculoplastic surgeons.
The procedures are “two completely different surgeries,” and there is no reason for them to be bundled together, Lee said.
“[The American Society of Ophthalmic Plastic and Reconstructive Surgery] was adamant to make changes. The former rule forced us to either do blepharoptosis repairs and no-charge blepharoplasties, or blepharoptosis repairs alone, without removing the excess skin that naturally bunches when the lid is lifted, which may not be in the best interest of the patient,” Lee said.
Under the prior regulation, patients could not self-pay for a blepharoplasty. If they wanted to pay out of pocket, CMS was basically saying they could not do so ever, Lee said.
“The rule banned them from having excess skin, cosmetic or not, removed. Why should CMS be regulating what we do cosmetically when it has nothing to do with insurance payers? The unbundling was a huge leap for us, and it was the right thing to do. To dictate what patients can do cosmetically or dictating what they can pay for out of their own pocket did not make sense,” she said.
The new billing structure will be similar to how surgeons billed patients for these procedures before the July 2016 policy, Lee said. – by Robert Linnehan
- Reference:
- CMS slightly alters stance on unbundling same-day blepharoplasty and blepharoptosis surgery. https://www.corcoranccg.com/news/cms-slightly-alters-stance-unbundling-day-blepharoplasty-blepharoptosis-surgery/. Published Sept. 5, 2017. Accessed Sept. 26, 2017.
- For more information:
- Kevin J. Corcoran, COE, CPC, CPMA, FNAO, can be reached at Corcoran Consulting Group, 560 East Hospitality Lane, Suite 360, San Bernardino, CA 92408; email: kcorcoran@corcoranccg.com.
- Wendy W. Lee, MD, can be reached at Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St., Miami, FL 33136; email: wlee@med.miami.edu.
Disclosures: Corcoran reports he is the president and co-owner of Corcoran Consulting Group. Lee reports no relevant financial disclosures.