Blepharoplasty - CPT/HCPCS Codes - 15822, 67900, 67924


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 describe conditions that may necessitate blepharoplasty:
  • Dermatochalasis: Excessive skin of the upper eyelid, usually the result of the aging process with loss of elasticity.
  • Blepharochalasis: Excessive skin of the eyelid, 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.
Blepharoplasty procedures and repair of blepharoptosis and anesthesia for these procedures are covered only 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.
  • There are prosthesis difficulties in an anophthalmic socket.
Medicare expects that the above-noted conditions will be appropriately documented and able to be visualized in the supportive photographs or videos maintained as part of the patient record.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet Only Manual IOM Pub. 100-04 Claims Processing Manual for further guidance.
Revenue codes have not been identified for these procedures, as they can be performed in a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360) or clinic (0510). Providers should report these HCPCS codes under the revenue center where they were performed.
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
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-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67916, 67917, 67923 and 67924:
Covered for:
368.40
Visual field defect, unspecified
373.4–373.6
Inflammation of eyelids
374.00–374.05
Entropion and trichiasis of eyelid
374.10–374.14
Ectropion
374.30–374.34
Ptosis of eyelid
374.51
Xanthelasma
374.56
Other degenerative disorders of skin affecting eyelid
374.87
Dermatochalasis
375.15
Tear film insufficiency, unspecified
701.8
Other specified hypertrophic and atrophic condition of skin
728.4
Laxity of ligament
743.61–743.62
Congenital anomalies of eyelids
V52.2
Artificial eye
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Documentation should consist of the following:
  • History and physical.
  • Operative report.
  • 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 15822© blepharoplasty and15823© blepharoplasty; upper eyelid with excessive skin weighing down lid 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, which must be maintained within the patient’s medical records:
  • Visual fields recorded to demonstrate an absolute superior defect to within 15 degrees of fixation.
  • Upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket.
  • Essential blepharospasm or hemifacial spasm.
  • 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.

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