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Blepharoplasty

Description

Surgery of the upper and lower eyelids and eyebrows is designed to provide functional visual field benefits and enhance the aesthetic appearance. A carefully executed examination and treatment plan is paramount to successful surgical results. The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia or developmental errors.

The following are terms used to described conditions which may require blepharoplasty:

· Dermatochalasis: Excessive skin, usually the result of the aging process with loss of elasticity.

· Blepharochalasis: Excessive skin usually associated with the disease process of chronic blepharoedema which physically stretches and thins the skin.

· Blepharoptosis: Drooping of the upper eyelid which relates to the position of the eyelid margin with respect to the eyeball and visual axis.

· Pseudoptosis: "False ptosis"- The eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis, however, the amount of excessive skin is so great it overhangs the eyelid margin and creates its own ptosis.

· Ptosis: Drooping of the upper eyelid.

Indication and Limitations of Coverage and/or Medical Necessity

Blepharoplasty procedures and repair of blepharoptosis and anesthesia for these procedures will be considered covered when performed as functional/reconstructive corrective surgery and when:

· Documented ptosis, pseudoptosis or dermatochalasis is present;

· There is interference with vision or visual field;

· There is difficulty reading due to upper eyelid drooping;

· The patient is looking through the eyelashes or seeing the upper eyelid skin;

· There is chronic blepharitis;

· There is visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis;

· There is symptomatic redundant skin weighing down on upper lashes;

· There is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin; or,

· There are prosthesis difficulties in an anophthalmic socket.

CPT/HCPCS Codes


00103©	Anesth, blepharoplasty
15822©	Revision of upper eyelid
15823©	Revision of upper eyelid
67900©	Repair brow defect
67901©	Repair eyelid defect
67902©	Repair eyelid defect
67903©	Repair eyelid defect
67904©	Repair eyelid defect
67906©	Repair eyelid defect
67908©	Repair eyelid defect
67916©	Repair eyelid defect
67917©	Repair eyelid defect
67923©	Repair eyelid defect
67924©	Repair eyelid defect

ICD-9 Codes that Support Medical Necessity

373.4	Infective dermatitis of eyelid of types resulting in deformity
373.5	Other infective dermatitis of eyelid
373.6	Parasitic infestation of eyelid
374.00	Entropion, unspecified
374.01	Senile entropion
374.02	Mechanical entropion
374.03	Spastic entropion
374.04	Cicatricial entropion
374.05	Trichiasis without entropion
374.10	Ectropion, unspecified
374.11	Senile ectropion
374.12	Mechanical ectropion
374.13	Spastic ectropion
374.14	Cicatricial ectropion
374.30	Ptosis of eyelid, unspecified
374.31	Paralytic ptosis
374.32	Myogenic ptosis
374.33	Mechanical ptosis
374.34	Blepharochalasis
374.51	Xanthelasma
374.87	Dermatochalasis
375.15	Tear film insufficiency, unspecified
743.61	Congenital ptosis
743.62	Congenital deformities of eyelids
V52.2	Artificial eye

Reasons for Denial

· All other indications not listed in the "Indications and Limitations of Coverage" section of this policy;

· The medical record does not verify that the service described by the HCPCS code was provided;

· The service does not follow the guidelines of this policy; and,

· The service is considered: investigational;

o for cosmetic purposes;

o for routine screening;

o a program exclusion;

o otherwise not covered; or,

o never medically necessary.

Non-covered ICD-9 Code(s)

All diagnoses not listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this policy.

Coding Guidelines

When photographs are performed, report the procedure with procedure code 92285©, external ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography); and,

Procedure code 92285 may be reported only once even though mulitple views may be taken.

Documentation Requirements

Documentation should consist of the following:

o history and physical;

o operative report;

o visual fields; and,

o Note: Visual fields must be recorded using either a tangent screen visual field, Goldmann Perimeter (III 4-E test object) or a programmable automated perimeter.

The field should be tested from fixation to a vertical extent of 30 degrees above fixation with targets presented at a minimum of four degrees vertical and horizontal separation. Each eye should be tested with the upper eyelid at rest to demonstrate the degree of impairment (there is no need to tape the lids to demonstrate an expected "surgical" improvement).

Visual fields are not required when the reason for the lid surgery is entropion (374.00-374.05) or ectropion (374.10-374.14).

photographs/video.

Note: When photographs, slides or videos are taken, they must be frontal, canthus-to-canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudolid margin. The photographs, slides or videos must be of sufficient clarity to show a light reflex on the cornea. If redundant skin coexists with true lid ptosis, additional photographs, slides or videos may be taken with the upper lid skin retracted to show the actual position of the true lid margin (needed if both codes blepharoplasty (15822) and blepharoplasty; upper eyelid with excessive skin weighing down lid (15823), are required and planned in addition to codes 67901-67908). Oblique views are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.

The following should be supported through photographs, slides or videos and visual field testing which are to be maintained within the patient’s medical records:

o visual fields recorded to demonstrate an absolute superior defect to within 15 degrees of fixation;

o upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket;

o essential blepharospasm or hemifacial spasm; and,

o significant ptosis in the downgaze reading position.

Note: If both a blepharoplasty and a brow ptosis repair are planned, both must be individually documented. This may require two sets of photographs, slides or videos showing the effect of drooping of redundant skin (and its correction by taping) and the actual presence of blepharoptosis. Photographs, slides or videos do not need to be submitted with the claim, but should remain part of the patient's medical record and available to Medicare upon request.