CMS slightly alters stance on unbundling same-day Blepharoplasty and Blepharoptosis Surgery

September 6, 2017

06-09-2017 Sandy Stofa closed

The Centers for Medicare & Medicaid (CMS), in a MLN Matters article dated August 25, 2017, has very slightly altered the previous stance on coverage for cosmetic blepharoplasty when performed in conjunction with blepharoptosis surgery. These SMALL but important changes do not go into effect until October 1, 2017. Surgeons and facilities should familiarize themselves with the important change to one specific part of the guidance. The previous July 2016 guidance, MM9658 Revised, can be accessed here. The NEW guidance, MM10236, leaves in place nearly all of the provisions from July 2016 but notes:

“ … effective October 1, 2017, CMS is revising this policy to allow either cosmetic or medically necessary blepharoplasty to be performed in conjunction with a medically necessary upper eyelid blepharoptosis surgery. Specifically, physicians may receive payment for a medically necessary upper eyelid blepharoptosis from Medicare even when performed with (non-covered) cosmetic blepharoplasty on the same eye during the same visit. Since cosmetic procedures are not covered by Medicare, advance beneficiary notice of noncoverage (ABN) instructions would apply for cosmetic blepharoplasty. However, medically necessary blepharoplasty will continue to be bundled into the payment for blepharoptosis when performed with and as a part of a blepharoptosis surgery. Other aspects of the July 2016 OPPS Update CR and MLN guidance on upper eyelid blepharoplasty and blepharoptosis remain unchanged …”

It is very important that surgeons and facilities understand the subtle change, since the new guidance will clearly affect how practices provide documentation and support.

If the blepharoplasty and blepharoptosis are both functional (non-cosmetic), then bundles remain in effect and only blepharoptosis is billed. The functional blepharoplasty is bundled and is not billed to anyone.
The bundles affect both surgeon and facility as the new guidance make clear.
If the blepharoptosis and blepharoplasty are both cosmetic, no bundles are in effect.
Only when the blepharoptosis is functional and the repair of it results in a cosmetic (non-functional) desire for improved eyelid appearance due to moving the lid margin upwards will the surgeon and facility be allowed to bill the patient for the cosmetic blepharoplasty and Medicare for the functional blepharoptosis surgery.
How to document and support a cosmetic procedure when another is functional in the same eyelid may differ by Medicare Administrative Contractor (MAC). An ABN is certainly indicated as noted above. Polices will change to reflect this since 10/01/2017 is soon.
Private payers and Medicare Part C plans might have different guidance and forms, and some private payers might not follow the above at all.

We are happy to help with this or other documentation and coding concerns. Please contact us via one of the below or on our “App”, Corcoran 24/7 which can be accessed via one of the below links.