67850_R37

1.  Optometrist’s or ophthalmologist’s services should be submitted with a diagnosis code to support medical necessity and should be coded to the greatest level of accuracy and highest level of digit completeness.  

2.  Medical records obtained by the eye doctor should clearly document the medical necessity for the lesion(s) destruction if a Contractor is billed for the service.  The relevant history and physical finding conforming to the criteria stated in the “Indication and Limitations of Coverage and/or Medical Necessity” section above should be made available to the Contractor on request.

3.  Surgical Procedures Lesions and Closures:  Operative notes for surgical procedures performed in the office location may be contained in the patient’s medical record for the date of service or as a separate report maintained within the patient’s chart.  The operative note for the procedure performed should be of significant detail to support the surgical procedure billed.  The surgical technique used should be described.  Surgical procedures should include the lesion size(s) location(s) and number.

4.  The decision to submit a specimen for pathological interpretation will be independent of the decision to destroy or not destroy the lesion.  It is assumed, however, that the pathology description and tissue diagnosis will be part of the medical record if a specimen is submitted to pathology.

5.  The medical record statement of “irritated skin lesion” is insufficient justification for lesion destruction when solely used to reference a patient’s complaint or a physician’s physical findings.  Similarly, use of diagnosis code L82.0, inflamed seborrheic keratosis, is insufficient to justify lesion destruction without medical documentation of the patient’s symptoms and physical findings.

The type of destruction is at the discretion of the treating optometrist or ophthalmologist and the appropriateness of the technique used will not be a factor in deciding if a lesion merits destruction. 

The decision to submit a specimen for pathologic interpretation will be independent of the decision to destroy or not destroy the lesion.  It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is destroyed based on physician uncertainty as to the final clinical diagnosis.

1.   Report a Destruction of Lesion of Eyelid Margin with CPT code 67850.  For services requiring a referring/ordering eye doctor, the name and NPI of the referring/ordering eye doctor should be reported on the claim.

2.   A claim submitted without a valid ICD-10-CM diagnosis code will likely be returned to the provider as an incomplete.

3.   The diagnosis code should best describe the patient’s condition for which the service was performed.

4.   Destruction of lesion of eyelid margin has a 10-day global period.  An evaluation and management code or ophthalmological service is not separately payable on the same day as this procedure unless a separately identifiable service is provided and documented in which case, it would be appropriate to attach modifier -25 to the examination code.  During the 10-day global period, additional eye examinations or surgical procedures may not be paid unless there is an explanatory modifier attached to the eye examination code and/or the surgical procedure code.  In these cases, the modifier -24 (unrelated examination service by the same doctor during a postoperative period) would be appended to the service line with the eye examination and the modifier -79 (unrelated procedure/service by the doctor during the postoperative period) would be appended to the service line with the surgical procedure.

5.   CPT code 67850 is a unilateral code and should be submitted with a site modifier (LT, RT, or -50).  Only one of these modifiers may be billed on a claim line.  Bilateral services should be billed with a -50 modifier, rather than RT and LT modifier.

6.   Depending on the Contractor, you may need to append an eyelid modifier (-E1, upper left, eyelid; -E2, lower left, eyelid; -E3, upper right, eyelid; or -E4, lower right, eyelid) or modifier -51 (multiple procedures) — or perhaps even both.  To date, Humana insurance is the only payor that requires these eyelid site modifiers to report the service.

7.   Destruction of lesion of eyelid is elective surgery and generally pre-scheduled.  It is usually inappropriate to report an examination service with a -25 modifier on the same date of service for the usual pre/post-operative care associated with this surgery.

In general, destruction of lesion of eyelid margin is reimbursed when it is reasonable and medically necessary.  Since there are no published Medicare utilization guidelines for this procedure, eye doctors should adhere to CMS Ruling 95-1 (V) which states that utilization of this procedure should be consistent with locally acceptable standards of practice.