In the past week, all the RAC region contractors have posted surgical procedure blepharoplasty as an approved complex audit review. At issue is whether the procedure was done to correct a deficit or for cosmetic reasons.

Blepharoplasty is the repair of the eyelid, and refers to an operation in which extra skin, muscle, and/or fat are removed. Functional blepharoplasty involves the excision of skin and orbicularis muscle. Blepharoplasty is 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 the repair is done for cosmetic purposes, it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medically necessary, and therefore will be denied by Medicare.

The issue references the Medicare Claims Processing and Benefit Policy manuals and the Local Coverage Determination policy for blepharoplasty, outlining guidelines for coding, documentation, and medical necessity criteria.

Medicare reimbursement is considered only for those procedures meeting the definition of reconstructive surgery and when the procedure is deemed medically necessary. Cosmetic surgery is not a covered service under Medicare.

RAC issues for the week of July 8–July 12, 2013:

RAC Region A Performant

DME Supplier Claim Types

  • Glucose Monitors Unbundling – Jurisdiction A – HCPCS codes A4233, A4234, A4235, A4236, A4256, and A4258, which describe glucose monitor supplies, will be denied when billed with the same date of service as glucose monitor HCPCS codes E0607, E2100 or E2101, as indicated in NHIC’s Local Coverage Determination (LCD) L11530 and related Article A33614.

RAC Region B CGI

Outpatient Hospital Claim Types

  • Outpatient Hospital Annual Wellness Visit Reported More than Allowed – WPS – The Annual Wellness Visit (AWV), either Initial or Subsequent, are only allowed to be reported no more than once per year per beneficiary. There are instances where professional and institutional claims are submitted for the AWV on the same date of service resulting in an overpayment of services.

RAC Region D HDI

Professional Services (Physician/Non-Physician Practitioner) Claim Types

  • Maximum Allowed Units for Part B Drugs and Biologicals – Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code descriptor. Palmetto GBA has developed maximum allowed units (MAU), modeled from the medically unbelievable edits (MUE) implemented by CMS. Drugs and biologicals submitted with quantities that exceed the Palmetto GBA established maximum limits will be denied unless additional supporting documentation is submitted for consideration.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

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