SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Blepharoplasty

A56439

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56439
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Blepharoplasty
Article Type
Billing and Coding
Original Effective Date
10/01/2018
Revision Effective Date
10/27/2022
Revision Ending Date
11/01/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33944-Blepharoplasty.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Other Comments:

For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS rvices to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for blepharoplasty services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

Associated Information:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please see "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. This documentation must be submitted upon request. Claims submitted without requested supporting evidence in the medical record will be denied as being not medical necessary.

In addition, for the Group 2 ICD-10-CM codes and Group 2 CPT codes listed in the A56439 Billing and Coding Article Blepharoplasty, documentation should consist of visual field results and/or photographs.


In cases of induction of visually compromising dermatochalasis by ptosis repair in patients having large dehiscence of the levator aponeurosis documentation must demonstrate:
a.Dehiscence of the levator aponeurosis; and

b.An operative note indicating the skin excess after the ptosis has been repaired and blepharoplasty is necessary.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
013x Hospital Outpatient
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
076X Specialty Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(10 Codes)
Group 1 Paragraph

The CPT codes in Group 1 are generally considered reconstructive in nature.

Group 1 Codes
Code Description
67909 REDUCTION OF OVERCORRECTION OF PTOSIS
67911 CORRECTION OF LID RETRACTION
67914 REPAIR OF ECTROPION; SUTURE
67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION
67916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE
67917 REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)
67921 REPAIR OF ENTROPION; SUTURE
67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION
67923 REPAIR OF ENTROPION; EXCISION TARSAL WEDGE
67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)

Group 2

(11 Codes)
Group 2 Paragraph

The CPT codes in Group 2 may potentially be considered as cosmetic and thus not covered by Medicare. Documentation to support functional impairment, visual or otherwise, must be present. (Please see the "Indications and Limitations" and "Documentation Requirements" sections in the policy L33944-Blepharoplasty.)

Group 2 Codes
Code Description
15820 BLEPHAROPLASTY, LOWER EYELID;
15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD
15822 BLEPHAROPLASTY, UPPER EYELID;
15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)
67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)
67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)
67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH
67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH
67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA)
67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(187 Codes)
Group 1 Paragraph

It is the responsibility of the physician/provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Some lid surgeries are generally considered reconstructive in nature and therefore do not require additional specific documentation for coverage by Medicare. Other diagnoses that are not listed within this article can only be considered on a case-by-case basis when the procedures performed are not for cosmetic purposes and they are submitted with the appropriate supportive medical documentation.

For CPT codes 15820-15823 with/or without 67900-67908 and 67909-67924:

Group 1 Codes
Code Description
C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including canthus
C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.131 Sebaceous cell carcinoma of skin of unspecified eyelid, including canthus
C44.1321 Sebaceous cell carcinoma of skin of right upper eyelid, including canthus
C44.1322 Sebaceous cell carcinoma of skin of right lower eyelid, including canthus
C44.1391 Sebaceous cell carcinoma of skin of left upper eyelid, including canthus
C44.1392 Sebaceous cell carcinoma of skin of left lower eyelid, including canthus
C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus
C44.301 Unspecified malignant neoplasm of skin of nose
C44.309 Unspecified malignant neoplasm of skin of other parts of face
C44.311 Basal cell carcinoma of skin of nose
C44.319 Basal cell carcinoma of skin of other parts of face
C44.321 Squamous cell carcinoma of skin of nose
C44.329 Squamous cell carcinoma of skin of other parts of face
C44.391 Other specified malignant neoplasm of skin of nose
C44.399 Other specified malignant neoplasm of skin of other parts of face
C44.90 - C44.92 Unspecified malignant neoplasm of skin, unspecified - Squamous cell carcinoma of skin, unspecified
C44.99 Other specified malignant neoplasm of skin, unspecified
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
D04.111 Carcinoma in situ of skin of right upper eyelid, including canthus
D04.112 Carcinoma in situ of skin of right lower eyelid, including canthus
D04.121 Carcinoma in situ of skin of left upper eyelid, including canthus
D04.122 Carcinoma in situ of skin of left lower eyelid, including canthus
D22.111 Melanocytic nevi of right upper eyelid, including canthus
D22.112 Melanocytic nevi of right lower eyelid, including canthus
D22.121 Melanocytic nevi of left upper eyelid, including canthus
D22.122 Melanocytic nevi of left lower eyelid, including canthus
D22.30 Melanocytic nevi of unspecified part of face
D22.39 Melanocytic nevi of other parts of face
D23.111 Other benign neoplasm of skin of right upper eyelid, including canthus
D23.112 Other benign neoplasm of skin of right lower eyelid, including canthus
D23.121 Other benign neoplasm of skin of left upper eyelid, including canthus
D23.122 Other benign neoplasm of skin of left lower eyelid, including canthus
D23.30 Other benign neoplasm of skin of unspecified part of face
D23.39 Other benign neoplasm of skin of other parts of face
G24.5 Blepharospasm
G51.0 Bell's palsy
G51.2 Melkersson's syndrome
G51.31 Clonic hemifacial spasm, right
G51.32 Clonic hemifacial spasm, left
G51.33 Clonic hemifacial spasm, bilateral
G51.4 Facial myokymia
G51.8 Other disorders of facial nerve
G51.9 Disorder of facial nerve, unspecified
G70.00 Myasthenia gravis without (acute) exacerbation
H01.001 Unspecified blepharitis right upper eyelid
H01.002 Unspecified blepharitis right lower eyelid
H01.004 Unspecified blepharitis left upper eyelid
H01.005 Unspecified blepharitis left lower eyelid
H01.00A Unspecified blepharitis right eye, upper and lower eyelids
H01.00B Unspecified blepharitis left eye, upper and lower eyelids
H01.01A Ulcerative blepharitis right eye, upper and lower eyelids
H01.01B Ulcerative blepharitis left eye, upper and lower eyelids
H01.02A Squamous blepharitis right eye, upper and lower eyelids
H01.02B Squamous blepharitis left eye, upper and lower eyelids
H02.001 Unspecified entropion of right upper eyelid
H02.002 Unspecified entropion of right lower eyelid
H02.004 Unspecified entropion of left upper eyelid
H02.005 Unspecified entropion of left lower eyelid
H02.011 Cicatricial entropion of right upper eyelid
H02.012 Cicatricial entropion of right lower eyelid
H02.014 Cicatricial entropion of left upper eyelid
H02.015 Cicatricial entropion of left lower eyelid
H02.021 Mechanical entropion of right upper eyelid
H02.022 Mechanical entropion of right lower eyelid
H02.024 Mechanical entropion of left upper eyelid
H02.025 Mechanical entropion of left lower eyelid
H02.031 Senile entropion of right upper eyelid
H02.032 Senile entropion of right lower eyelid
H02.034 Senile entropion of left upper eyelid
H02.035 Senile entropion of left lower eyelid
H02.041 Spastic entropion of right upper eyelid
H02.042 Spastic entropion of right lower eyelid
H02.044 Spastic entropion of left upper eyelid
H02.045 Spastic entropion of left lower eyelid
H02.051 Trichiasis without entropion right upper eyelid
H02.052 Trichiasis without entropion right lower eyelid
H02.054 Trichiasis without entropion left upper eyelid
H02.055 Trichiasis without entropion left lower eyelid
H02.101 Unspecified ectropion of right upper eyelid
H02.102 Unspecified ectropion of right lower eyelid
H02.104 Unspecified ectropion of left upper eyelid
H02.105 Unspecified ectropion of left lower eyelid
H02.111 Cicatricial ectropion of right upper eyelid
H02.112 Cicatricial ectropion of right lower eyelid
H02.114 Cicatricial ectropion of left upper eyelid
H02.115 Cicatricial ectropion of left lower eyelid
H02.121 Mechanical ectropion of right upper eyelid
H02.122 Mechanical ectropion of right lower eyelid
H02.124 Mechanical ectropion of left upper eyelid
H02.125 Mechanical ectropion of left lower eyelid
H02.131 Senile ectropion of right upper eyelid
H02.132 Senile ectropion of right lower eyelid
H02.134 Senile ectropion of left upper eyelid
H02.135 Senile ectropion of left lower eyelid
H02.141 Spastic ectropion of right upper eyelid
H02.142 Spastic ectropion of right lower eyelid
H02.144 Spastic ectropion of left upper eyelid
H02.145 Spastic ectropion of left lower eyelid
H02.151 Paralytic ectropion of right upper eyelid
H02.152 Paralytic ectropion of right lower eyelid
H02.154 Paralytic ectropion of left upper eyelid
H02.155 Paralytic ectropion of left lower eyelid
H02.156 Paralytic ectropion of left eye, unspecified eyelid
H02.159 Paralytic ectropion of unspecified eye, unspecified eyelid
H02.201 Unspecified lagophthalmos right upper eyelid
H02.202 Unspecified lagophthalmos right lower eyelid
H02.204 Unspecified lagophthalmos left upper eyelid
H02.205 Unspecified lagophthalmos left lower eyelid
H02.20A Unspecified lagophthalmos right eye, upper and lower eyelids
H02.20B Unspecified lagophthalmos left eye, upper and lower eyelids
H02.20C Unspecified lagophthalmos, bilateral, upper and lower eyelids
H02.211 Cicatricial lagophthalmos right upper eyelid
H02.212 Cicatricial lagophthalmos right lower eyelid
H02.214 Cicatricial lagophthalmos left upper eyelid
H02.215 Cicatricial lagophthalmos left lower eyelid
H02.21A Cicatricial lagophthalmos right eye, upper and lower eyelids
H02.21B Cicatricial lagophthalmos left eye, upper and lower eyelids
H02.21C Cicatricial lagophthalmos, bilateral, upper and lower eyelids
H02.221 Mechanical lagophthalmos right upper eyelid
H02.222 Mechanical lagophthalmos right lower eyelid
H02.224 Mechanical lagophthalmos left upper eyelid
H02.225 Mechanical lagophthalmos left lower eyelid
H02.22A Mechanical lagophthalmos right eye, upper and lower eyelids
H02.22B Mechanical lagophthalmos left eye, upper and lower eyelids
H02.22C Mechanical lagophthalmos, bilateral, upper and lower eyelids
H02.231 Paralytic lagophthalmos right upper eyelid
H02.232 Paralytic lagophthalmos right lower eyelid
H02.234 Paralytic lagophthalmos left upper eyelid
H02.235 Paralytic lagophthalmos left lower eyelid
H02.23A Paralytic lagophthalmos right eye, upper and lower eyelids
H02.23B Paralytic lagophthalmos left eye, upper and lower eyelids
H02.23C Paralytic lagophthalmos, bilateral, upper and lower eyelids
H02.411 - H02.413 Mechanical ptosis of right eyelid - Mechanical ptosis of bilateral eyelids
H02.421 - H02.423 Myogenic ptosis of right eyelid - Myogenic ptosis of bilateral eyelids
H02.431 - H02.433 Paralytic ptosis of right eyelid - Paralytic ptosis of bilateral eyelids
H02.521 Blepharophimosis right upper eyelid
H02.522 Blepharophimosis right lower eyelid
H02.524 Blepharophimosis left upper eyelid
H02.525 Blepharophimosis left lower eyelid
H02.531 Eyelid retraction right upper eyelid
H02.532 Eyelid retraction right lower eyelid
H02.534 Eyelid retraction left upper eyelid
H02.535 Eyelid retraction left lower eyelid
H02.70 Unspecified degenerative disorders of eyelid and periocular area
H04.521 - H04.523 Eversion of right lacrimal punctum - Eversion of bilateral lacrimal punctum
H50.89 Other specified strabismus
H57.811 Brow ptosis, right
H57.812 Brow ptosis, left
H57.813 Brow ptosis, bilateral
Q10.0 - Q10.3 Congenital ptosis - Other congenital malformations of eyelid
Q11.1 Other anophthalmos
S04.51XA Injury of facial nerve, right side, initial encounter
S04.52XA Injury of facial nerve, left side, initial encounter
T85.21XA Breakdown (mechanical) of intraocular lens, initial encounter
T85.22XA Displacement of intraocular lens, initial encounter
T85.29XA Other mechanical complication of intraocular lens, initial encounter
Z44.21 Encounter for fitting and adjustment of artificial right eye
Z44.22 Encounter for fitting and adjustment of artificial left eye
Z90.01 Acquired absence of eye

Group 2

(36 Codes)
Group 2 Paragraph

It is the responsibility of the physician/provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Lid surgeries done for the following ICD-10-CM may potentially be considered as cosmetic and thus not covered by Medicare without the appropriate documentation to support functional impairment. Please see the “Documentation Requirements in the policy L33944-Blepharoplasty."

 

For CPT codes 15820-15823 with/or without 67900-67908 and 67909-67924:

 

Group 2 Codes
Code Description
H02.31 Blepharochalasis right upper eyelid
H02.32 Blepharochalasis right lower eyelid
H02.34 Blepharochalasis left upper eyelid
H02.35 Blepharochalasis left lower eyelid
H02.401 - H02.403 Unspecified ptosis of right eyelid - Unspecified ptosis of bilateral eyelids
H02.831 Dermatochalasis of right upper eyelid
H02.832 Dermatochalasis of right lower eyelid
H02.834 Dermatochalasis of left upper eyelid
H02.835 Dermatochalasis of left lower eyelid
H02.881 Meibomian gland dysfunction right upper eyelid
H02.882 Meibomian gland dysfunction right lower eyelid
H02.884 Meibomian gland dysfunction left upper eyelid
H02.885 Meibomian gland dysfunction left lower eyelid
H02.88A Meibomian gland dysfunction right eye, upper and lower eyelids
H02.88B Meibomian gland dysfunction left eye, upper and lower eyelids
H02.89 Other specified disorders of eyelid
H02.9 Unspecified disorder of eyelid
L11.8 Other specified acantholytic disorders
L11.9 Acantholytic disorder, unspecified
L57.2 Cutis rhomboidalis nuchae
L57.4 Cutis laxa senilis
L66.4 Folliculitis ulerythematosa reticulata
L85.8 Other specified epidermal thickening
L87.1 Reactive perforating collagenosis
L87.8 Other transepidermal elimination disorders
L90.3 Atrophoderma of Pasini and Pierini
L90.4 Acrodermatitis chronica atrophicans
L90.8 Other atrophic disorders of skin
L91.8 Other hypertrophic disorders of the skin
L92.2 Granuloma faciale [eosinophilic granuloma of skin]
L94.8 Other specified localized connective tissue disorders
L98.5 Mucinosis of the skin
L98.6 Other infiltrative disorders of the skin and subcutaneous tissue
L99 Other disorders of skin and subcutaneous tissue in diseases classified elsewhere
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
Z41.1 Encounter for cosmetic surgery
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
013x Hospital Outpatient
085x Critical Access Hospital
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.


Code Description
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
076X Specialty Services - General Classification
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/27/2022 R9

Revision Effective: 10/27/2022

Revision Explanation: Annual Review, no changes

10/21/2021 R8

Revision Effective: 10/21/2021

Revision Explanation: Annual Review, no changes

11/07/2019 R7

Revision Effective: N/A

Revision Explanation: Annual Review, no changes

11/07/2019 R6

Revision Effective: 11/07/2019

Revision Explanation: Annual Review. Updated article text with other comments from Coverage Indications, Limitations and/or Medical Necessity based on TDL 190550. Added details from LCD L33944.

11/07/2019 R5

R4

Revision Effective: 11/07/2019

Revision Explanation: Annual Review. Updated article text with Associated Information based on TDL 190550. Added details from LCD L33944.

09/19/2019 R4

R4

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

10/01/2018 R3

R3

Revision Effective: 10/08/2018

Revision Explanation: ICD-10 code H02.401-H02.403 were listed in group 1 in error. These codes should have been listed in group 2 and have been moved into this grouping.

10/01/2018 R2

R2

Revision Effective: N/A

Revision Explanation: Correction to typographical error within Group 1 paragraph.

10/01/2018 R1

R1

Revision Effective:10/01/2018

Revision Explanation: Add ICD-10 code H57.811-H57.813 for brow ptosis that were new from ICD-10 annual update.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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