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New Issue for RACs – Blepharoplasty

During the month of June, all four Recovery Audit Contractors (RACs) added a new issue for auditing that affects ophthalmology.

Blepharoplasty was added for review for physician services, hospital services, and ambulatory surgery centers. The review is listed as a “complex” review, which means that medical records will be requested prior to any overpayment demand letter.

Performant Recovery, previously known as Diversified, RAC for Region A, published the issue as follows:

Issue Name:

Blepharoplasty – Eyelid Lifts

Issue Number:

A008142013

Issue Description:

Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will denied.

Type of Review:

Complex

State(s) Impacted:

CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT

Provider Type:

Physician / Nonphysician Practitioner

Date Posted:

June 19, 2013

Date Revised:

No Revision

Dates of Service:

Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.

 

The other three RACs published a similar description.

If you receive a RAC review request for this service, be mindful of submitting all the necessary information to support the medical necessity of the surgery. Include an exam with patient complaints, visual field studies, external photos, and an operative report.

Please contact us if you have questions, or are unsure about your documentation. We are happy to work with you if you get a request for records, as well.

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