Guidelines for reporting blepharoptosis tissue removal

Q: Our surgeons perform a lot of blepharoptosis repairs. Because each patient is different, different amounts of eyelid tissue has to be removed. One of our surgeons wants to set a maximum amount that is included in the procedure and then charge a blepharoplasty to cover anything over and above this maximum. We are trying to figure out how to even start to operationalize this. It seems to us that this is just a “patient differential” in the surgery like you have in any other surgery. Is there any guidance or standard for this?

A: There is no industry standard for the amount of tissue that is removed for a specific procedure. Many procedures require measurements of the tissue or weighing of the tissue in order to assign the appropriate CPT or HCPCS Level II code. But there is nothing that states if you remove more than “X”  tissue, then you have a second procedure.

In the July 2016 OPPS update, CMS addresses this issue. Transmittal 3523 provides specific guidelines and prohibitions regarding these procedures. Basically, any eyelid work performed during a blepharoptosis repair is part of the procedure. If additional eyelid tissue is removed, even if it might be considered as cosmetic surgery, the “additional tissue” cannot be billed to the patient as a cosmetic surgery–it is considered to be part of the blepharoptosis.

No Advance Beneficiary Notice may be issued and the patient may not be held liable for any part of the procedure. CMS is also watching for “splitting” of procedures, meaning the separation of procedures on the same eye or performing separate procedures on different days when the standard of care is to perform a bilateral procedure.

The full set of guidelines is documented in the transmittal.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.