Upper Eyelid Blepharoplasty and Blepharoptosis Repair

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Oct 3rd, 2016 - Reviewed/Updated Aug 1st

The Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) ontheipsilateral upper eyelid. Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is considered apart of the blepharoptosis surgery.

A blepharoplasty cannot be billed to Medicare and the beneficiary cannot be separately charged for a cosmetic procedure regardless of the amount of upper eyelid skin that is removed on a patient receiving a blepharoptosis repair because removal of any amount of upper eyelid skin is part of the blepharoptosis repair. In addition, the following are not permitted:

• Operating on the left and right eyes on different days when the standard of care is bilateral eyelid surgery

• Charging the beneficiary an additional amount for a cosmetic blepharoplasty when a blepharoptosis repair is performed

• Charging the beneficiary an additional amount for removing orbital fat when a blepharoplasty or a blepharoptosis repair is performed

• Performing a blepharoplasty on a different date of service than the blepharoptosis procedure for the purpose of unbundling the blepharoplasty or charging the beneficiary for a cosmetic surgery

• Performing blepharoplasty as a staged procedure, either by one or more surgeons (note that under certain circumstances a blepharoptosis procedure could be a staged procedure)

• Billing for two procedures when two surgeons divide the work of a blepharoplasty performed with a blepharoptosis repair

• Using modifier 59 to unbundle the blepharoplasty from the ptosis repair on the claim form; this applies to both physicians and facilities

• Treating medically necessary surgery as cosmetic for the purpose of charging the beneficiary for a cosmetic surgery

• Using an Advance Beneficiary Notice of Noncoverage (ABN) for a service that would be bundled into another service if billed to Medicare

• In the rare event that a blepharoplasty is performed on one eye and a blepharoptosis repair is performed on the other eye, the services must each be billed with the appropriate RT or LT modifier.