Coding & Reimbursement

Lower Eyelid Surgery: Cosmetic vs. Reconstructive

By Suzanne L. Corcoran, COE

Cosmetic surgery is performed to improve appearance while reconstructive surgery is performed to restore or improve function, although incidental improvement in appearance may also occur. This month we will continue to address this issue and examine some of the implications for lower eyelid surgery.

A malpositioned lower eyelid manifests as entropion (i.e., turned inward toward the globe) or ectropion (i.e., turned outward away from the globe). Entropion is caused by age-related tissue relaxation, postinfectious or posttraumatic change, or blepharospasm. Eyelashes rub against the eyeball and may lead to corneal ulceration and scarring. Symptoms can include foreign body sensation, tearing and red eye.

Ectropion is caused by age-related tissue relaxation, cranial nerve VII palsy and posttraumatic or postsurgical changes. Symptoms include tearing due to poor drainage of tears through the nasolacrimal system, which may no longer contact the eyeball, as well as symptoms of dry eyes with superficial keratitis, possibly due to inadequate blinking.

Surgery involves either shortening/tightening tissues, or lengthening with grafts or spacers to restore normal eyelid position and function. In cases involving cicatricia as well, surgical grafting is combined with the ectropion/entropion repair.

As with upper eyelid surgery, fillers and botulinum toxin are helpful for improving cosmesis, as well as blepharoplasty for wrinkles and bags.

Most Medicare policies do not currently require external photos to document the amount of entropion or ectropion, but they can be helpful and we recommend them. Useful photos are close up and show detail. Depending on the extent of the malformation, side photos may also be helpful in documenting the patient's problems.

As always, a thorough history is required, and take care to document the patient's complaints.

Notations of previously unsuccessful therapies are also key to documenting medical necessity for insurance coverage of these procedures.

The distinction between cosmetic surgery and reconstructive or functional surgery is generally based on the following:

► Patient's complaint(s) and history
► Findings of the examination and key measurements
► Results of diagnostic tests
► Purpose and extent of the surgery

Table 1 (below) identifies essential hallmarks to help you make this distinction.

Once you have made a fair determination whether the proposed surgery is cosmetic or reconstructive according to the current policy of the payer, and have documented your findings and decision-making in the medical record, then you can discuss financial responsibility with the patient while scheduling the surgery. Obvious cases with clear-cut hallmarks may be handled with confidence, but borderline cases need finesse as well as a contingency plan for financial reversals.

The best tool is a financial waiver form. Ask Medicare beneficiaries to sign an Advance Beneficiary Notice of Noncoverage. Prepayment is expected. For other payers, prior authorization is the best approach where applicable; use a Notice of Exclusion from Health Plan Benefits where it is not. In either case, if the payer determines that the procedure is medically necessary, covered and subject to their allowable fee schedule, refund the beneficiary's prepayment. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.