Q: Can CPT code 67840 excision of lesion of eyelid (except chalazion) without closure or with simple direct closure be used universally for removing eyelid lesions?

A: No. This code falls under the heading of "Eyelids," "Excision." The code states: "Codes for removal of lesion include more than skin (i.e., involving lid margin, tarsus and/or palpebral conjunctiva)." If the excision involves only skin, you must choose a code from the integumentary portion of the CPT code book.

Q: How do you choose a code for lesion removal when you don't know if it is benign or malignant?

A: To code the lesion removal accurately, you must wait until you receive the pathology report.

Q: Is the removal of a skin lesion covered by Medicare?

A: Sometimes. Medicare covers malignant lesion removal. Removal of benign lesions is covered if the patient has a complaint, such as irritation, discharge or bleeding. When you remove lesions without a medical complaint (e.g., for uncertain pathology), it is in the interests of the practice and the patient that the patient sign an Advanced Beneficiary Notice before the procedure, and append a GA modifier to the CPT code. If the lesion is benign, the patient's responsible for the charge. The new ABN mandated by HIPAA allows you to collect the fee and then reimburse the patient if the carrier later determines the procedure to be medically necessary.

Q: Several skin codes are based on size. How is that determined?

A: With implementation of the 2003 CPT code book came a change in how we choose among 114xx and 116xx series of codes. Once based on the lesion size, it is now based on the size of the excision, including the narrowest margin around the actual lesion. This is beneficial for the surgeon, especially for the malignant lesions, where the excision is often significantly larger and more complex to close than the benign cases. The size of the lesion should still be documented in the chart and some discussion regarding the need for the larger excision. When the excision is measured, be sure to measure the tissue removed not the resulting wound.

Q: If a functional blepharoplasty is planned, what documentation should be in the chart?

A: Most importantly, a patient complaint of visual interference due to the dermatochalasis, and ideally, a lifestyle complaint as well. The clinic notes must discuss that the disease is significant and etiologically responsible for the patient complaint. Some policies require external photography from the front and the side, and it's helpful in all cases. The patient should look straight ahead and the photographer should be on the same plane as the subject's visual axis, close enough to include only the patient's eyes. The correct code is: 92885 external ocular photography with interpretation and report for documentation of medical progress. There is debate regarding coverage of the photos prior to blepharoplasties because they are used primarily for documentation purposes, not diagnostic purposes. Check your local carrier for coverage rules. Some policies also require visual fields; these are always advised in order to support the medical necessity of the procedure. The customary "bleph field" is a single isopter or single stimulus test, especially focused on the superior half of the visual field. It is most often done with the lids at rest and elevated (taped) to demonstrate the amount of visual field lost to the lids. The correct code is: 92081 visual field examination, unilateral or bilateral, with interpretation and report; limited examination. The test when done twice is best described with the modifier-76, repeat procedure by same physician, but it is not always recognized.

Q: Can blepharoplasties be performed in the ASC?

A: It's always been permissible to do blepharoplasties in an ASC. Not until March 28, 2003 were they eligible for facility reimbursement in ASCs. Lower lid blepharoplasties (15820, 15821) and upper blepharoplasty (15822) are assigned to Group 3, and an upper lid blepharoplasty with excessive skin weighing down the lid (15823) to Group 5. Before these new ASC rules, it was unclear whether the patient could be charged for the facility fee.

Q: If an eyelid ptosis repair is planned, what documentation should be in the chart?

A: The patient complaint and interference with lifestyle activities are key. The clinic chart should have measurements showing diminished levator function, including measurement of the palpebral fissures, margin to reflex distance, and levator function. Photos help demonstrate lid encroachment on the pupil. This data is especially important when performing a concurrent ptosis/blepharoplasty procedure. Carefully document that the patient has two diseases.

Contact Ms. Kennedy, an associate consultant with the Corcoran Consulting Group, at 1 (800) 399-6565 or pkennedy@corcoranccg.com.