Upper Eyelid Blepharoplasty and Blepharoptosis Repair (update eff 10/01/2017)

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Oct 3rd, 2016 - Reviewed/Updated Aug 2nd

Effective October 1, 2017, CMS revised this policy to allow either cosmetic or medically necessary blepharoplasty to be performed in conjunction with a medically necessary upper eyelid blepharoptosis surgery. Specifically, physicians may receive payment for a medically necessary upper eyelid blepharoptosis from Medicare even when performed with (non-covered) cosmetic blepharoplasty on the same eye during the same visit. Since cosmetic procedures are not covered by Medicare, advanced beneficiary notice of noncoverage instructions would apply for cosmetic blepharoplasty. However, medically necessary blepharoplasty will continue to be bundled into the payment for blepharoptosis when performed with and as a part of a blepharoptosis surgery.

CMS previously stated in 2016 the following:  

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.

Other aspects of the July 2016 ASC Update CR and MLN guidance on upper eyelid blepharoplasty and blepharoptosis remain unchanged. 

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. 

- CMS Pub-100 (update for ASC - Eff Oct 2017)

– Noridian Healthcare Solutions (July 2016 Update)