Around 11.5% of adults in the USA have a droopy eyelid, but only a few know the disorder is treatable. The standard treatment method for this condition is surgery, covered by CPT code 15823.
Unfortunately, many plastic surgeons around the country are unaware of the nuances of this procedural code, such as its correct descriptor, use cases, applicable modifiers, and billing best practices. As a result, insurance payers deny reimbursements for their claims with CPT 15823.
In today’s detailed guide, we will explore all you need to know about CPT code 15823 to help you bypass the extremely high 28% claim denial rate for plastic surgeries.
CPT Code 15823 – Description
The Current Procedural Terminology (CPT) code 15823 reports an upper eyelid revision surgery to improve the function and appearance of the eyelid. It is a cosmetic procedure, classified under the code range ‘Other Repair (Closure) Procedures on the Integumentary System’ as maintained by the American Medical Association (AMA).
In medical terminology, this cosmetic surgery is known as blepharoplasty or an eyelid lift. It is the most common treatment method for correcting droopy eyelids or ptosis. During the procedure, the surgeon trims or excises the excess skin, muscle, or fat weighing down the eyelid. Heavy eyelids hamper the patient’s vision, causing straining and headaches.
Medicare covers CPT code 15823. The current Medicare reimbursement rate for blepharoplasty on the upper eyelid to remove excessive skin is between $482.64 and $772.12, depending on the MAC facility and locality.
Scenarios Where CPT Code 15823 is Applicable
Now that you understand what CPT code 15823 entails, let’s look at some practical scenarios where this code is applicable.
Functional Blepharoplasty for Droopy Eyelids (Ptosis)
For our first example, we will discuss the need for a functional blepharoplasty or upper eyelids lift for a condition known as acquired ptosis or droopy eyelids in adults. In adults, the eyelids start to sag when the levator muscles weaken or become separated from the eyelids. It can partially or wholly block the patient’s vision, affecting the normal functioning of the eyes. The most common cause of acquired ptosis is aging.
So, imagine that a 68-year-old woman with droopy eyelids visits the cosmetic surgeon upon the referral of her ophthalmologist. Her vision is partially obstructed due to the sagging eyelids, resulting in strain and headaches. The cosmetic surgeon performs a functional blepharoplasty on both of her upper eyelids by excising the excess skin, which weighs down the eyelids. The incision is stitched after the excess skin removal.
Since the surgery was performed to improve the patient’s vision, it will be considered medically necessary and covered by insurance. The surgeon will use CPT code 15823 to bill the procedure and append modifier 50 to highlight bilaterality. Hence, it will be coded as 15823-50.
Cosmetic Blepharoplasty to Improve the Appearance of an Eyelid
For our second example, we will use the same patient, but this time, assume that the reason for her blepharoplasty is to improve the appearance of her affected eyelid. In this case, her condition, known as acquired ptosis or droopy eyelid, does not impact her vision. However, she is insecure about her appearance and wants it corrected.
The surgeon performs cosmetic blepharoplasty on her right upper eyelid. He removes the excess skin and tissue to minimize droopiness and carefully stitches up the incision on the eyelid.
Since the procedure was performed for cosmetic reasons, the patient’s insurance payer (Medicare) will not cover it. The surgeon will still submit a claim using CPT code 15823 but will append the modifier GY to trigger an automatic claim denial and transfer the financial responsibility onto the patient. Hence, the procedure will be coded as 15823-GY.
Blepharoplasty for Congenital Ptosis, Unilateral
When droopy eyelids or ptosis occurs in infants or children, it is known as congenital ptosis. It implies that the child was born with the condition because of developmental issues with the levator muscle. Just like adults, the condition may affect one or both eyelids in children.
For this particular example, we will consider a 2-year-old toddler who was born with congenital ptosis. The levator muscle in his left upper eyelid could not develop properly, causing a droopy eyelid. The condition hampers the toddler’s vision, making blepharoplasty medically necessary.
The surgeon performs the procedure and bills it using CPT code 15823 to collect accurate reimbursement from the insurance payer.
Applicable Modifiers for CPT Code 15823
In medical coding, modifiers are two-digit codes that provide supplemental information to the insurance payer regarding the circumstances under which the procedure or service was performed. Classified as pricing, payment, and location modifiers, they are appended with the CPT code in the exact order and may affect the final reimbursement rate.
The following modifiers are most commonly appended with CPT code 15823 for supplemental information and accurate reimbursement. Take a look.
Modifier 50
Modifier 50 explains a bilateral procedural. Appending modifier 50 to CPT code 15823 would indicate that the eyelid lift was performed on both eyelids during the same session.
Modifier RT
CPT code 15823 is inherently a unilateral procedure. It means that the code covers the removal of excess skin, tissue, or muscle from one of the upper eyelids. However, for coding specificity, it is better to use the appropriate modifier and inform the insurance payer on which upper eyelid the procedure was performed since eyes are paired body parts.
Using modifier RT will indicate that the surgical procedure was performed on the right upper eyelid.
Modifier LT
Just like modifier RT, modifier LT also specifies unilaterality and location. So, if the procedure was performed on the left upper eyelid, you should append modifier LT with CPT code 15823.
Modifier GA
Modifier GA is typically appended to Medicare claims. It indicates that a Waiver of Liability Statement or an Advance Beneficiary Notice (ABN) was issued to the patient, informing them of their financial responsibility in case Medicare refuses to cover blepharoplasty on the upper eyelid.
Modifier GY
Since CPT code 15823 reports a cosmetic procedure, Medicare will not cover it if the reason is to improve the appearance of the patient’s upper eyelids and eyes. In this case, the eyelid lift will not qualify as a Medicare benefit.
However, surgeons or their billing teams may append modifier GY to CPT code 15823 to explain that the service is statutorily excluded, which will lead to an automatic claim denial and make the patient responsible for the full cost of the procedure.
CPT Code 15823 – Billing & Reimbursement Guidelines
Your fair reimbursement for CPT code 15823 relies upon your billing accuracy. To submit clean and compliant claims that get accepted on the first attempt, refer to the billing and reimbursement guidelines for CPT 15823 discussed below.
Ensure Accurate Code Pairing
Remember that insurance payers only reimburse your practice for CPT code 15823 if the upper eyelid lift is medically necessary. To prove the medical necessity of blepharoplasty, you must pair CPT 15823 with the most appropriate ICD-10 diagnosis code.
The Centers for Medicare and Medicaid Services (CMS) provides a list of ICD-10-CM codes that support medical necessity for excessive skin, tissue, or muscle removal from an upper eyelid (CPT code 15823). For example, you can pair it with Q10.0 if the reason for blepharoplasty was congenital ptosis.
Maintain Comprehensive Documentation
Another best practice is to maintain detailed documentation and submit it with the claim form to prove the medical necessity of the surgical procedure. Medicare Part B covers functional blepharoplasty. However, you must review the Medicare Administrative Contractors’ (MACs’) local coverage determinations (LCDs) to familiarize yourself with the coverage policies and documentation requirements. For example, your documentation for CPT code 15823 should include:
- Functional patient complaint (not cosmetic)
- The physician’s documented order, mentioning which tests were performed, on which eye, and how those tests were performed.
- The patient’s name and date of service for each test
- The physician’s interpretation and test reports
- Margin reflex distance (MRD) measurement
- The patient’s consent for the surgery
- Surgery outcomes
- The patient’s postoperative treatment plan
Follow Payer-Specific Policies
Medicare, Medicaid, and most commercial payers cover an upper eyelid lift for functional reasons. However, you must follow their specific billing guidelines and policies to ensure compliance and submit error-free claims.
It is recommended that you review each payer’s contract to determine exclusions and limitations before creating claims. It will help you avoid unnecessary paperwork and the stress of reworking denied claims.
Refer to the NCCI Edits Bundling Rules
According to the National Correct Coding Initiative (NCCI) edits, CPT code 15823 is bundled with visual field examination CPT codes 92081-92083 and blepharoptosis procedure CPT codes 67901-67908. Therefore, you cannot bill these codes separately for a higher reimbursement.
Use Modifiers when Appropriate
You must also use the correct modifiers when needed to ensure coding specificity. For example, you can use modifier 50 if the surgical procedure took place on both eyes during the same session or modifier GA if the procedure was performed for cosmetic reasons and the patient signed an ABN to bear the financial responsibility in case of a Medicare denial.
Summary
We understand that in the case of comprehensive guides, it can be a challenge to recall the specifics once you are done reading them. To aid your retention, let’s quickly revisit the key information we learned. CPT code 15823 reports a blepharoplasty of an upper eyelid to improve the appearance and function of the eyelid.
Some practical scenarios where this code can be reported are functional blepharoplasty for acquired and congenital ptosis and cosmetic blepharoplasty for improved appearance. Moreover, you must maintain documentation and use modifiers when needed for accurate billing of CPT code 15823.
If you want to streamline your medical coding process and ensure quick collections against your submitted claims, outsource plastic surgery billing services to professionals at MediBillMD.
