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04/27/2012

CGS Clarifies Blepharoplasty Policy and Creates New System Allowing Faxed Documentation

We know OOS members have been having challenges getting Blepharoplasty claims paid since last summer. This week CGS posted the following information clarifying the blepharoplasty policy (in addition a blepharoplasty checklist has been created) and announcing providers will be able to fax documentation starting May 1. Read the CGS postings below. 

Coverage Requirements for Blepharoplasty (LCD L31828) and Checklist

Blepharoplasty may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. It may be either reconstructive or cosmetic (aesthetic). When blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids (ptosis); repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion corneal exposure); treat periorbital sequalae of thyroid disease and nerve palsy; or relieve the painful symptoms of blepharospasm, the procedure should be considered reconstructive. This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally a graft of skin or other distant tissues is transplanted to replace deficient eyelid components.  Surgery of the upper eyelids is reconstructive when it provides functional vision and/or visual field benefits or improves the functioning of a malformed or degenerated body member, but cosmetic when done to enhance aesthetic appearance. The goal of functional restorative surgery is to restore significant function to a structure that has been altered by trauma, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors.

The goal of this procedure is to correct significant visual impairment-supported by documented patient complaints which justify functional surgery.
Diagnoses/Conditions which may require repair                              

  • Dermatochalasis
  • Blepharochalasis
  • Pseudoptosis
  • Brow Ptosis
  • Horizontal Eyelid Laxity

Examples of patient complaints CGS is seeing:

  • Significant interference with superior and/or lateral visual fields
  • Difficulty reading or “heaviness” of eyelids during reading resulting in muscle fatigue
  • Eyelashes and/or eyelids blocking normal visual fields; patient complains of “looking through” eyelashes
  • Excessive watering or tearing of eyes related to eyelash irritation
  • Eye fatigue/increased visual field loss in afternoon or evening as compared to morning

Visual Field Study Testing Requirements               :             

  • Demonstrate a significant loss of superior and/or lateral visual fields
  • Minimum of 12 degrees or 30% loss of upper field of vision
  • Indicate potential correction by proposed procedure
  • Must be recorded with:
  • A tangent screen visual field

Other acceptable documentation:

  • Kinetic Goldmann perimetry test
  • Other programmable automated perimeter screening field
    • Single intensity strategy
    • 10dB stimulus
    • Superior (vertical) extent of 50-60 degrees above fixation
    • Targets at a minimum four-degree separation starting at zero degrees above fixation while using no wider than a 10-degree horizontal separation   

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(1)(10) prohibits payment for cosmetic surgery. Procedures performed only to approve appearances without a functional benefit are not covered by Medicare

CGS has created a Blepharoplasty Checklist.

New Process: Faxing Unsolicited Documentation to Accompany an Initial Claim – Ohio Providers

Beginning May 1, 2012, you will have the option of faxing hard copy unsolicited documentation to accompany your electronically-submitted claims. This process will allow providers an opportunity to submit additional documentation to support their claim at the time the claim is initially submitted for processing. In most cases, this will reduce the number of CGS-generated requests for additional documentation related to those claims. However, providers should not fax documentation in response to a CGS-solicited documentation request letter; providers should continue to send CGS-generated requests for additional documentation by mail, using the instructions outlined in your documentation request letter.

When submitting unsolicited documentation to accompany an initial electronic claim, please use the following process:

  1. On your electronic claim, you must add the word "FAX" in the Comments or NTE (note) segment field.
  2. After the claim has been accepted by CGS, complete the Fax Cover Sheet, which will be available on our website by 05/01/2012. The Fax Cover Sheet should not be modified by the provider or trading partners. Additionally, the Fax Cover Sheet may be returned if it is incomplete or incorrectly filled out. We will only return the fax sheet; not the documentation.
  3. Fax the Cover Sheet with all necessary documentation.(the form will include the relevant fax number). Please note, CGS will allow seven calendar "waiting" days for documentation to be received from the provider for any electronic claim that contains the "FAX" indicator in the NTE segment.
  4. CGS will process the claim and will refer to your submitted faxed documentation, if necessary for proper claim adjudication.

The information provided in this article is intended to assist you in understanding when it is appropriate to fax documentation. When considering whether or not to fax documentation, please keep the following tips in mind:

  1. Faxing unsolicited documentation is entirely voluntary

    Under current claim processing rules, if a Medicare contractor determines that additional information is needed to complete proper adjudication of a claim (for instance, due to an audit), then the contractor will send you a development letter requesting additional documentation. This process will not change. If you believe your claim may result in a development request, then it may be a good idea to fax documentation to accompany your initial electronic claim in order to expedite claim processing time.

  2. The NTE (note) segment is still a valid option

    Faxing unsolicited documentation is not always the best option for including additional claim information. The NTE (note) segment of an electronic claim is currently available for you to include notes and information that may be important for the proper adjudication of the claim. If you can use the NTE segment instead of the faxing documentation, we encourage you to do so.

  3. Do not fax unsolicited documentation unless it is needed

    Medicare rules and regulations require that you keep certain documentation on file in order to support the medical necessity and justification of your claims (medical records, progress notes, etc.); however, you are not required to submit this documentation with your claim. We encourage you to only submit supporting claim documentation when you believe it may be required in order to correctly process your claim. Examples of when it might be appropriate to fax additional documentation along with your initial claim include, but are not limited to:

    • Claims containing unlisted procedures
    • Modifier 22 claims
    • Modifier 53 claims
    • Claims requiring invoice information
    • Claims for co-surgery, assistant surgery, or team surgery when the code being billed has an MPFSDB indicator that requires supporting documentation for medical necessity for co-surgery, assistant surgery or team surgery.
  4. Faxing of documentation does not guarantee that the J15 MAC will review the submitted paperwork

    When processing your claims, we may look for additional information in the NTE segment in order to complete your claim; however, use of the NTE segment or faxing documentation does not mean that we will always review the information. We will only review your additional information when it is needed in order to properly process payment. For instance, if a claim is submitted with a modifier that precludes payment for the service, the claim will deny without our claim processors looking at the NTE or the faxed documentation.

We are pleased to be able to provide you with this new option for submitting documentation. Should you have questions regarding this process, please contact our Customer Service Call Center at: 1-866-276-9558.


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