Coding & Reimbursement

What Qualifies as Cosmetic Surgery?

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 examine some of the implications for upper eyelid surgery.

Cosmetic vs. Reconstructive

The distinction between cosmetic surgery and reconstructive or functional surgery is based on a patient's complaint(s) and history, findings of the examination and key measurements, results of diagnostic tests and the purpose and extent of the surgery.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Minimally invasive procedures such as injections of fillers or botulinum toxin can quickly improve appearance, pose small risk and are nearly always considered cosmetic procedures. Blepharoplasty for rhytids (i.e., wrinkles of the skin) is likewise performed for aesthetic improvement.

Cosmetic surgery is statutorily excluded from Medicare coverage. Medicare and other payers publish rules to differentiate between covered and noncovered procedures. Payers tend to automatically categorize eyelid and brow surgery as cosmetic. If reimbursement is expected, it's essential that the chart documentation contain the necessary information to support a medically necessary procedure. Check each payer's coverage policy.

Coding Particulars

CPT does not designate particular codes as either cosmetic or functional. Procedures to address anophthalmos, neoplasms, reconstruction after Mohs surgery, trauma, lagophthalmos or ptosis would usually be functional. Coverage policies generally require at least one of the following:

• the upper eyelid margin within 2.5 mm of the corneal light reflex (margin reflex distance (MRD) <2.5mm) with patient in primary gaze
• the upper eyelid skin rests on eyelashes
• the upper eyelid indicates dermatitis
• the upper eyelid position contributes to difficulty tolerating a prosthesis
• the brow position is below the superior orbital rim.

External ocular photographs demonstrate grossly malpositioned eyelids interfering with vision, and many payers require them. Photographs in primary, up and down gaze are usually required; photos at 45° from the mid-line are helpful as a side view to show protrusion or skin folded over on itself. Useful photographs are close-ups that show detail and permit easy interpretation, not full-face photos.

A small MRD results from a significant droop of the upper eyelid, generally due to the skin weighing on the eyelashes or “hooding,” which is graded as moderate or severe in the chart notes. As a consequence of the visual obstruction by the eyelid, a visual field defect can be readily demonstrated centrally and temporally, and obvious improvement shown when the eyelids are taped up.

Some payer policies detail the amount of visual field impairment and potential improvement required. Typically, this is: “the upper visual field must improve by at least eight degrees or 20% with the eyelid taped up as compared to the visual field obtained without taping, and visual field obstruction by the eyelid must limit the upper visual field to within 30° of fixation.”

Operative reports should include a sentence or two at the beginning describing the indications for surgery. This anticipates the (likely) request for chart documentation after the fact and makes it easy to respond. In combined cases, it's particularly helpful to differentiate between the portion of the surgery that is reconstructive and the remainder which is cosmetic (e.g., functional upper eyelid blepharoplasty at the same operative session as a cosmetic lower eyelid blepharoplasty); do not split the operative report into two documents, do make clear what was done and why.

Payers and surgeons do not always agree on the medical necessity for lid surgery. Patients may press the surgeon to show that the surgery should be covered by insurance. Some surgeons prefer to categorize borderline cases as cosmetic to avoid accepting a lower fee under the assignment provisions of the payer.

So, counseling of patients must deal with uncertainty of future reimbursement except in the most straightforward situations. When in doubt, get an Advance Beneficiary Notice of Noncoverage for Medicare patients, and a Notice of Exclusion from Health Plan Benefits for others. Collect payment in advance. OM

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