Knowledge Base Article

Cosmetic surgery is a booming business in America. In 2014, Americans spent over $12 billion on cosmetic procedures. The top five surgical cosmetic procedures for 2014 included breast augmentation, nose reshaping, liposuction, eyelid surgery, and facelift. A recent Medicare transmittal discusses the correct billing of eyelid surgery (cosmetic or otherwise) when performed in addition to another eyelid procedure.

Do you know the difference in blepharoplasty and blepharoptosis repair? Blepharoptosis is a drooping eyelid which results in an abnormal, low-lying upper eyelid margin. Ptosis repair raises the eyelid height by tightening the muscles that elevate the eyelid.   Blepharoplasty involves removing excess skin and/or fat. If there is so much excess skin/fat that it interferes with vision it may be medically necessary and covered by insurance. Most blepharoplasty procedures are cosmetic, performed to improve the appearance of the eyes. Medicare does not cover cosmetic surgery unless it is needed because of accidental injury or to improve the function of a malformed body part. Upper eyelid ptosis repair may include the removal of excess upper lid tissue to further improve eyesight, especially on older patients.

Per clarification in the July 2016 OPPS Update, any removal of upper eyelid tissue (blepharoplasty) performed in conjunction with a ptosis repair of the same eye is considered a part of the blepharoptosis repair and may not be billed separately to Medicare or to the patient. The article also includes a list of other billing practices that Medicare does not allow related to blepharoplasty / blepharoptosis procedures:

• Operating on left and right eyes on different days when a bilateral procedure would have been appropriate
• Charging the patient for a cosmetic blepharoplasty performed in conjunction with a blepharoptosis procedure
• Charging the patient for removing orbital fat performed in conjunction with either a blepharoplasty or blepharoptosis procedure
• Performing the blepharoplasty on a different day from the blepharoptosis repair procedure in order to bill for both
• Performing blepharoplasty as 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
• Charging the patient for a cosmetic procedure when the surgery was medically necessary and should have been billed to Medicare
• Shifting financial liability to the patient using an Advance Beneficiary Notice of Noncoverage (ABN) for a bundled service

Sometimes a patient may need a blepharoplasty on one eye and a blepharoptosis repair on the other eye (although Medicare describes this as a rare event). In this case, it would be appropriate to bill both procedures with their respective RT and LT modifiers. If the blepharoplasty is medically necessary due to vision impairment, both procedures should be billed to Medicare. If the blepharoplasty is for cosmetic reasons, the ptosis would be billed to Medicare and the patient is responsible for payment of the blepharoplasty cosmetic procedure.

It might take a nip here and a tuck there to achieve bodily perfection but to be “perfect” in Medicare billing, providers need to know the rules, understand the rules and follow CMS guidance.