ASC Compliance & Coding

ASC Surgical Reimbursement for Eyelid Malpositions

By Riva Lee Asbell

Successful and optimal ASC reimbursement for eyelid malpositions depends on several issues: cosmetic versus functional designation, proper chart documentation, correct assignment of financial responsibility, Medicare's guidelines and policies, and legal issues. This article is based on Medicare rules and regulations and may vary with other insurers.

Cosmetic Versus Functional Surgery

Eyelid malposition surgery with a dual classification of either cosmetic or functional includes blepharoplasty, blepharoptosis repair, and brow ptosis repair.

When a cosmetic procedure is performed not only is the patient responsible for the surgeon's fee, but also for the facility fee and the anesthesia fee. If a given case is partially functional then the patient is responsible for those parts of the surgical, anesthesia and facility fee attributable to the cosmetic portion.

If a procedure is performed that the facility was reimbursed for is later determined to be cosmetic, any monies paid to an ASC will be recouped.

Chart Documentation

Mainly errors of omission rather than errors of commission fall into this category. Each ASC chart should be able to stand on its own in terms of audit – and that includes documentation that may already be in the physician's patient chart but is not placed in the ASC chart. Most of these deal with medical necessity issues.

Since Medicare only pays for cases deemed functional and containing the proper chart documentation supporting a functional status, it is imperative that ASC records, in addition to the physician records, support this.

I recommend that a copy of the physician's office note for the day that the surgery was scheduled be incorporated into the ASC chart. The chart note should support the designation of functional, if the case is being scheduled as such, and meet all the requirements listed by your Medicare carrier. Medical necessity issues are documented by doing this.

A typical guideline found in Medicare policies would be as follows:

Blepharoplasty procedures will be considered covered when performed as functional/reconstructive surgery to correct any of the following:

• Visual impairment due to dermatochalasis or blepharochalasis
• Symptomatic redundant skin which is resting on upper lashes
• Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
• Prosthesis difficulties in an anophthalmic socket

Blepharoptosis repair is covered when performed as functional/reconstructive surgery to correct the following:

• Visual impairment due to droop or displacement of the upper lid
• Brow ptosis repair is covered when performed as functional/reconstructive surgery to correct the following:
• Visual impairment due to droop or displacement of the brow
• Brow malposition which would prevent adequate correction of dermatochalasis, blepharochalasis or blepharoptosis.

LCDs. Often your Medicare Administrative Contractor (MAC) has a LCD (Local Coverage Determination) regarding reimbursement on the surgeries. It is a good idea for those involved with ASC coding and billing to familiarize themselves with the requirements and ascertain that the physician has the proper documentation for the procedure.

Here are links to some of the policies:

Wisconsin Physician Services: http://wpsmedicare.com/part_a/policy/active/local/l29973_ophth022.shtml

Highmark Medicare: https://www.highmarkmedicareservices.com/policy/mac-ab/l27474-r6.html

Trailblazer: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2947

ADL Issues. Careful perusal of any of the policies reveals that the patient must have a clinically pathological or functional issue that interferes with Activities of Daily Living (ADL). They are enumerated in the policies. The ASC should have a copy of the physician's office visit chart that documents this when the surgery is scheduled.

Legal Issues

Legal issues abound when dealing with ASC compliance and reimbursement. It is best to consult with a qualified and reputable attorney who specializes in health care matters.

Inducement. There is an overall general lack of understanding of the consequences of either not adhering to or not being cognizant of the reimbursement requirements when cosmetic procedures are performed. Whenever a cosmetic procedure is performed and the aforementioned charges for anesthesia and facility fees are not charged to the patient — i.e., are waived by the ASC — the issue of inducement arises.

An ASC is required to charge the patient for various services that Medicare does not cover, as discussed above. For cosmetic procedures it is best to have the patient pay in advance any portion of the service attributable to cosmesis to avoid angry patients who claim they were not aware of the financial obligation.

Not Charging for Procedures. Often when surgeons are performing oculoplastic procedures they tell the patient “Oh, don't worry about that growth on your forehead, I'll take it off while we are doing the blepharoplasty” and fails to charge the patient and document the procedure thereby causing the ASC to be at fault for providing “free procedures”.

Falsifying Operative Notes. Many ASC personnel are not familiar with the subtleties of oculoplastic surgery. As abhorrent as it may seem to most physicians, there are many instances of falsifying operative notes in order to charge Medicare. An example of this is would be describing a lower eyelid blepharoplasty as an ectropion repair.

Highmark Medicare (cited above) states “Lower lid blepharoplasty is generally not reimbursable since it is usually performed for cosmetic reasons. Payment may be considered on an individual consideration basis when supportive documentation (e.g., patient's chief complaint, operative report, etc.) is included as part of the patient's medical record to demonstrate that the procedure is medically necessary for reconstructive reasons.”

Financial Issues

One of the disturbing issues that emerged last year was deciding how to code when blepharoplasty and ptosis surgeries were performed together. Since they are bundled under the National Correct Coding Initiative you no longer can be reimbursement for both and if you bill both you will be paid for the lower paying code. For physicians the higher paying code is the ptosis repair (CPT code 67904) whereas for the ASC it is upper eyelid blepharoplasty (CPT code 15823). The 2012 ASC national average reimbursement is $865.16 for 15823 and $798.08 for 67904.

Surgical Coding Issues

Surgical coding for the three conditions is rather straightforward; however, coding for ensuing complications may be more problematic. Surgical correction of complications arising from a cosmetic procedure may be billed to Medicare — such as scar revision following blepharoplasty surgery. However, the CPT codes to be used are found under integumentary system rather than in the eye section of CPT. You should not use the same procedure code again nor should CPT code 66250 is used– it is for intraocular cases only.

Q. I am the director of an ophthalmology ASC and have a question about coding blepharoplasties. Currently, we bill CPT 15823 and along with that a layered closure, CPT 12016. There are no CCI edits for billing these two codes together. We have asked many and some say it is okay and others say it is not okay. There, of course, is a big difference of opinion between physician billers versus ASC billers. Can you answer the question?

A. You cannot and should not do this. Closure of the incision is part of the global surgery and included in the global fee. CPT code 12016 is for wound repair not for closure of the incision.

Q. Does anyone know the CPT code for a patient for a procedure after a blepharoplasty involving scar revision to release laterally and reform crease medially?

A. This is an example of functional correction after a cosmetic procedure that Medicare will pay for. However, you do not recode the blepharoplasty procedure. The correct CPT codes are found in the Integumentary System section of CPT under “Repair”. The repair will be coded from the appropriate categories: Simple repair, Intermediate repair or Complex repair.

Q. The surgeon charges the patient for the removal of the medial fat pad during blepharoplasty and bills Medicare for the blepharoplasty also. Can an ASC do the same thing?

A. Neither the surgeon nor the ASC should be doing this. If the procedure is cosmetic the patient pays the entire amount and related fees; if the procedure is functional — the patient should not be billed for the medial fat pad removal by either entity. It is considered part of the blepharoplasty operation. ◊