Policyholder Services

Blepharoplasty a Leading Audit Topic that Practices Should Code Carefully

According to a recent audit report, contractors representing the Centers for Medicare and Medicaid Services are randomly requesting post-payment review of physician documentation for CPT code 15823 Blepharoplasty, upper eyelid; with excessive skin weighing down lid.

In recently published audit findings for California, Nevada and Hawaii and the Pacific Islands, claims for this code had denial rates between 68 and 74 percent. Denials were commonly linked to failure to show functional rather than cosmetic need. In particular, the audit report cited inadequate history reporting and photos and visual-field tests that were illegible or did not meet Medicare criteria. Lack of legible physician signature also contributed to the denials. Image quality problems have been compounded by auditor image issues, resulting in reversals of some audit findings on further review.

Definitions for functional blepharoplasty can vary by payer. Members should review their carriers’ local coverage determination to ensure they are coding according to the definition. For assistance, contact Academy Coding Executive Sue Vicchrilli at svicchrilli@aao.org. Providers insured with Ophthalmic Mutual Insurance Company should also contact the OMIC Claims Department to report an audit or other billing error proceeding. Call 800.562.6642 and choose option 3.