LCD Reference Article Billing and Coding Article

Billing and Coding: Blepharoplasty

A56439

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	MAC - Part A	15101 - MAC A	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part B	15102 - MAC B	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part A	15201 - MAC A	J - 15	Ohio
CGS Administrators, LLC	MAC - Part B	15202 - MAC B	J - 15	Ohio

Article Information

General Information

Article ID
A56439

Article Title
Billing and Coding: Blepharoplasty

Article Type
Billing and Coding

Original Effective Date
10/01/2018

Revision Effective Date
11/07/2024

Revision Ending Date
N/A

Retirement Date
N/A

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33944-Blepharoplasty.

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
Relevant medical history
Results of pertinent tests/procedures
Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Other Comments:

For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS rvices to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for blepharoplasty services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

Associated Information:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please see "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. This documentation must be submitted upon request. Claims submitted without requested supporting evidence in the medical record will be denied as being not medical necessary.

In addition, for the Group 2 ICD-10-CM codes and Group 2 CPT codes listed in the A56439 Billing and Coding Article Blepharoplasty, documentation should consist of visual field results and/or photographs.

In cases of induction of visually compromising dermatochalasis by ptosis repair in patients having large dehiscence of the levator aponeurosis documentation must demonstrate:
a.Dehiscence of the levator aponeurosis; and

b.An operative note indicating the skin excess after the ptosis has been repaired and blepharoplasty is necessary.

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(187 Codes)

Group 1 Paragraph

It is the responsibility of the physician/provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Some lid surgeries are generally considered reconstructive in nature and therefore do not require additional specific documentation for coverage by Medicare. Other diagnoses that are not listed within this article can only be considered on a case-by-case basis when the procedures performed are not for cosmetic purposes and they are submitted with the appropriate supportive medical documentation.

For CPT codes 15820-15823 with/or without 67900-67908 and 67909-67924:

Group 1 Codes

Code	Description
C44.1021	Unspecified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1022	Unspecified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1091	Unspecified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1092	Unspecified malignant neoplasm of skin of left lower eyelid, including canthus
C44.1121	Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122	Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191	Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192	Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221	Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222	Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291	Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292	Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.131	Sebaceous cell carcinoma of skin of unspecified eyelid, including canthus
C44.1321	Sebaceous cell carcinoma of skin of right upper eyelid, including canthus
C44.1322	Sebaceous cell carcinoma of skin of right lower eyelid, including canthus
C44.1391	Sebaceous cell carcinoma of skin of left upper eyelid, including canthus
C44.1392	Sebaceous cell carcinoma of skin of left lower eyelid, including canthus
C44.1921	Other specified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1922	Other specified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1991	Other specified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1992	Other specified malignant neoplasm of skin of left lower eyelid, including canthus
C44.301	Unspecified malignant neoplasm of skin of nose
C44.309	Unspecified malignant neoplasm of skin of other parts of face
C44.311	Basal cell carcinoma of skin of nose
C44.319	Basal cell carcinoma of skin of other parts of face
C44.321	Squamous cell carcinoma of skin of nose
C44.329	Squamous cell carcinoma of skin of other parts of face
C44.391	Other specified malignant neoplasm of skin of nose
C44.399	Other specified malignant neoplasm of skin of other parts of face
C44.90 - C44.92	Unspecified malignant neoplasm of skin, unspecified - Squamous cell carcinoma of skin, unspecified
C44.99	Other specified malignant neoplasm of skin, unspecified
C47.0	Malignant neoplasm of peripheral nerves of head, face and neck
C49.0	Malignant neoplasm of connective and soft tissue of head, face and neck
D04.111	Carcinoma in situ of skin of right upper eyelid, including canthus
D04.112	Carcinoma in situ of skin of right lower eyelid, including canthus
D04.121	Carcinoma in situ of skin of left upper eyelid, including canthus
D04.122	Carcinoma in situ of skin of left lower eyelid, including canthus
D22.111	Melanocytic nevi of right upper eyelid, including canthus
D22.112	Melanocytic nevi of right lower eyelid, including canthus
D22.121	Melanocytic nevi of left upper eyelid, including canthus
D22.122	Melanocytic nevi of left lower eyelid, including canthus
D22.30	Melanocytic nevi of unspecified part of face
D22.39	Melanocytic nevi of other parts of face
D23.111	Other benign neoplasm of skin of right upper eyelid, including canthus
D23.112	Other benign neoplasm of skin of right lower eyelid, including canthus
D23.121	Other benign neoplasm of skin of left upper eyelid, including canthus
D23.122	Other benign neoplasm of skin of left lower eyelid, including canthus
D23.30	Other benign neoplasm of skin of unspecified part of face
D23.39	Other benign neoplasm of skin of other parts of face
G24.5	Blepharospasm
G51.0	Bell's palsy
G51.2	Melkersson's syndrome
G51.31	Clonic hemifacial spasm, right
G51.32	Clonic hemifacial spasm, left
G51.33	Clonic hemifacial spasm, bilateral
G51.4	Facial myokymia
G51.8	Other disorders of facial nerve
G51.9	Disorder of facial nerve, unspecified
G70.00	Myasthenia gravis without (acute) exacerbation
H01.001	Unspecified blepharitis right upper eyelid
H01.002	Unspecified blepharitis right lower eyelid
H01.004	Unspecified blepharitis left upper eyelid
H01.005	Unspecified blepharitis left lower eyelid
H01.00A	Unspecified blepharitis right eye, upper and lower eyelids
H01.00B	Unspecified blepharitis left eye, upper and lower eyelids
H01.01A	Ulcerative blepharitis right eye, upper and lower eyelids
H01.01B	Ulcerative blepharitis left eye, upper and lower eyelids
H01.02A	Squamous blepharitis right eye, upper and lower eyelids
H01.02B	Squamous blepharitis left eye, upper and lower eyelids
H02.001	Unspecified entropion of right upper eyelid
H02.002	Unspecified entropion of right lower eyelid
H02.004	Unspecified entropion of left upper eyelid
H02.005	Unspecified entropion of left lower eyelid
H02.011	Cicatricial entropion of right upper eyelid
H02.012	Cicatricial entropion of right lower eyelid
H02.014	Cicatricial entropion of left upper eyelid
H02.015	Cicatricial entropion of left lower eyelid
H02.021	Mechanical entropion of right upper eyelid
H02.022	Mechanical entropion of right lower eyelid
H02.024	Mechanical entropion of left upper eyelid
H02.025	Mechanical entropion of left lower eyelid
H02.031	Senile entropion of right upper eyelid
H02.032	Senile entropion of right lower eyelid
H02.034	Senile entropion of left upper eyelid
H02.035	Senile entropion of left lower eyelid
H02.041	Spastic entropion of right upper eyelid
H02.042	Spastic entropion of right lower eyelid
H02.044	Spastic entropion of left upper eyelid
H02.045	Spastic entropion of left lower eyelid
H02.051	Trichiasis without entropion right upper eyelid
H02.052	Trichiasis without entropion right lower eyelid
H02.054	Trichiasis without entropion left upper eyelid
H02.055	Trichiasis without entropion left lower eyelid
H02.101	Unspecified ectropion of right upper eyelid
H02.102	Unspecified ectropion of right lower eyelid
H02.104	Unspecified ectropion of left upper eyelid
H02.105	Unspecified ectropion of left lower eyelid
H02.111	Cicatricial ectropion of right upper eyelid
H02.112	Cicatricial ectropion of right lower eyelid
H02.114	Cicatricial ectropion of left upper eyelid
H02.115	Cicatricial ectropion of left lower eyelid
H02.121	Mechanical ectropion of right upper eyelid
H02.122	Mechanical ectropion of right lower eyelid
H02.124	Mechanical ectropion of left upper eyelid
H02.125	Mechanical ectropion of left lower eyelid
H02.131	Senile ectropion of right upper eyelid
H02.132	Senile ectropion of right lower eyelid
H02.134	Senile ectropion of left upper eyelid
H02.135	Senile ectropion of left lower eyelid
H02.141	Spastic ectropion of right upper eyelid
H02.142	Spastic ectropion of right lower eyelid
H02.144	Spastic ectropion of left upper eyelid
H02.145	Spastic ectropion of left lower eyelid
H02.151	Paralytic ectropion of right upper eyelid
H02.152	Paralytic ectropion of right lower eyelid
H02.154	Paralytic ectropion of left upper eyelid
H02.155	Paralytic ectropion of left lower eyelid
H02.156	Paralytic ectropion of left eye, unspecified eyelid
H02.159	Paralytic ectropion of unspecified eye, unspecified eyelid
H02.201	Unspecified lagophthalmos right upper eyelid
H02.202	Unspecified lagophthalmos right lower eyelid
H02.204	Unspecified lagophthalmos left upper eyelid
H02.205	Unspecified lagophthalmos left lower eyelid
H02.20A	Unspecified lagophthalmos right eye, upper and lower eyelids
H02.20B	Unspecified lagophthalmos left eye, upper and lower eyelids
H02.20C	Unspecified lagophthalmos, bilateral, upper and lower eyelids
H02.211	Cicatricial lagophthalmos right upper eyelid
H02.212	Cicatricial lagophthalmos right lower eyelid
H02.214	Cicatricial lagophthalmos left upper eyelid
H02.215	Cicatricial lagophthalmos left lower eyelid
H02.21A	Cicatricial lagophthalmos right eye, upper and lower eyelids
H02.21B	Cicatricial lagophthalmos left eye, upper and lower eyelids
H02.21C	Cicatricial lagophthalmos, bilateral, upper and lower eyelids
H02.221	Mechanical lagophthalmos right upper eyelid
H02.222	Mechanical lagophthalmos right lower eyelid
H02.224	Mechanical lagophthalmos left upper eyelid
H02.225	Mechanical lagophthalmos left lower eyelid
H02.22A	Mechanical lagophthalmos right eye, upper and lower eyelids
H02.22B	Mechanical lagophthalmos left eye, upper and lower eyelids
H02.22C	Mechanical lagophthalmos, bilateral, upper and lower eyelids
H02.231	Paralytic lagophthalmos right upper eyelid
H02.232	Paralytic lagophthalmos right lower eyelid
H02.234	Paralytic lagophthalmos left upper eyelid
H02.235	Paralytic lagophthalmos left lower eyelid
H02.23A	Paralytic lagophthalmos right eye, upper and lower eyelids
H02.23B	Paralytic lagophthalmos left eye, upper and lower eyelids
H02.23C	Paralytic lagophthalmos, bilateral, upper and lower eyelids
H02.411 - H02.413	Mechanical ptosis of right eyelid - Mechanical ptosis of bilateral eyelids
H02.421 - H02.423	Myogenic ptosis of right eyelid - Myogenic ptosis of bilateral eyelids
H02.431 - H02.433	Paralytic ptosis of right eyelid - Paralytic ptosis of bilateral eyelids
H02.521	Blepharophimosis right upper eyelid
H02.522	Blepharophimosis right lower eyelid
H02.524	Blepharophimosis left upper eyelid
H02.525	Blepharophimosis left lower eyelid
H02.531	Eyelid retraction right upper eyelid
H02.532	Eyelid retraction right lower eyelid
H02.534	Eyelid retraction left upper eyelid
H02.535	Eyelid retraction left lower eyelid
H02.70	Unspecified degenerative disorders of eyelid and periocular area
H04.521 - H04.523	Eversion of right lacrimal punctum - Eversion of bilateral lacrimal punctum
H50.89	Other specified strabismus
H57.811	Brow ptosis, right
H57.812	Brow ptosis, left
H57.813	Brow ptosis, bilateral
Q10.0 - Q10.3	Congenital ptosis - Other congenital malformations of eyelid
Q11.1	Other anophthalmos
S04.51XA	Injury of facial nerve, right side, initial encounter
S04.52XA	Injury of facial nerve, left side, initial encounter
T85.21XA	Breakdown (mechanical) of intraocular lens, initial encounter
T85.22XA	Displacement of intraocular lens, initial encounter
T85.29XA	Other mechanical complication of intraocular lens, initial encounter
Z44.21	Encounter for fitting and adjustment of artificial right eye
Z44.22	Encounter for fitting and adjustment of artificial left eye
Z90.01	Acquired absence of eye

Group 2

(36 Codes)

Group 2 Paragraph

Lid surgeries done for the following ICD-10-CM may potentially be considered as cosmetic and thus not covered by Medicare without the appropriate documentation to support functional impairment. Please see the “Documentation Requirements in the policy L33944-Blepharoplasty."

For CPT codes 15820-15823 with/or without 67900-67908 and 67909-67924:

Group 2 Codes

Code	Description
H02.31	Blepharochalasis right upper eyelid
H02.32	Blepharochalasis right lower eyelid
H02.34	Blepharochalasis left upper eyelid
H02.35	Blepharochalasis left lower eyelid
H02.401 - H02.403	Unspecified ptosis of right eyelid - Unspecified ptosis of bilateral eyelids
H02.831	Dermatochalasis of right upper eyelid
H02.832	Dermatochalasis of right lower eyelid
H02.834	Dermatochalasis of left upper eyelid
H02.835	Dermatochalasis of left lower eyelid
H02.881	Meibomian gland dysfunction right upper eyelid
H02.882	Meibomian gland dysfunction right lower eyelid
H02.884	Meibomian gland dysfunction left upper eyelid
H02.885	Meibomian gland dysfunction left lower eyelid
H02.88A	Meibomian gland dysfunction right eye, upper and lower eyelids
H02.88B	Meibomian gland dysfunction left eye, upper and lower eyelids
H02.89	Other specified disorders of eyelid
H02.9	Unspecified disorder of eyelid
L11.8	Other specified acantholytic disorders
L11.9	Acantholytic disorder, unspecified
L57.2	Cutis rhomboidalis nuchae
L57.4	Cutis laxa senilis
L66.4	Folliculitis ulerythematosa reticulata
L85.8	Other specified epidermal thickening
L87.1	Reactive perforating collagenosis
L87.8	Other transepidermal elimination disorders
L90.3	Atrophoderma of Pasini and Pierini
L90.4	Acrodermatitis chronica atrophicans
L90.8	Other atrophic disorders of skin
L91.8	Other hypertrophic disorders of the skin
L92.2	Granuloma faciale [eosinophilic granuloma of skin]
L94.8	Other specified localized connective tissue disorders
L98.5	Mucinosis of the skin
L98.6	Other infiltrative disorders of the skin and subcutaneous tissue
L99	Other disorders of skin and subcutaneous tissue in diseases classified elsewhere

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
Z41.1	Encounter for cosmetic surgery

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code	Description
Please accept the License to see the codes.

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

Code	Description
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Other Coding Information

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
11/07/2024	R12	Revision Effective: 11/07/2024 Revision Explanation: Annual review, no changes.
11/16/2023	R11	Revision Effective: 11/16/2023 Revision Explanation: Updated LCD Reference Article section.
11/02/2023	R10	Revision Effective: 11/02/2023 Revision Explanation: Annual Review, no changes
10/27/2022	R9	Revision Effective: 10/27/2022 Revision Explanation: Annual Review, no changes
10/21/2021	R8	Revision Effective: 10/21/2021 Revision Explanation: Annual Review, no changes
11/07/2019	R7	Revision Effective: N/A Revision Explanation: Annual Review, no changes
11/07/2019	R6	Revision Effective: 11/07/2019 Revision Explanation: Annual Review. Updated article text with other comments from Coverage Indications, Limitations and/or Medical Necessity based on TDL 190550. Added details from LCD L33944.
11/07/2019	R5	R4 Revision Effective: 11/07/2019 Revision Explanation: Annual Review. Updated article text with Associated Information based on TDL 190550. Added details from LCD L33944.
09/19/2019	R4	R4 Revision Effective: 09/19/2019 Revision Explanation: Converted article into new Billing and Coding template no other changes made.
10/01/2018	R3	R3 Revision Effective: 10/08/2018 Revision Explanation: ICD-10 code H02.401-H02.403 were listed in group 1 in error. These codes should have been listed in group 2 and have been moved into this grouping.
10/01/2018	R2	R2 Revision Effective: N/A Revision Explanation: Correction to typographical error within Group 1 paragraph.
10/01/2018	R1	R1 Revision Effective:10/01/2018 Revision Explanation: Add ICD-10 code H57.811-H57.813 for brow ptosis that were new from ICD-10 annual update.

Associated Documents

Related Local Coverage Documents
LCDs
L33944 - Blepharoplasty

Updated On	Effective Dates	Status
10/29/2024	11/07/2024 - N/A	Currently in Effect	You are here
11/07/2023	11/16/2023 - 11/06/2024	Superseded	View
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Billing and Coding: Blepharoplasty

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