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The Florida Society of Ophthalmology

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Recent (April 1st) Denials for Bilateral Eyelid Procedures

Our Third Party Liaison Committee has been notified by a number of Florida ophthalmologists that they have been receiving denials from Medicare for bilateral eyelid procedures since April 1, 2013. Studies by the Government Accounting Office and the Office of Inspector General found that some providers (nationally) were being overpaid for bilateral surgery (modifier 50) procedures. Based on those findings, the Centers for Medicare and Medicaid Services (CMS) decided to notify the AMA that they would revise the Medically Unlikely Edits (MUE) program for the reporting of bilateral surgery procedures effective April 1, 2013.

These revisions were not supposed to include some of the bilateral ophthalmic procedure codes such as blepharoplasties, ptosis repairs, entropion and ectropion repairs, etc.  First Coast Service Options (FCSO), Florida Medicare, has been contacted by the FSO and is now aware that these edits are generating a lot of inappropriate denials. We have been instructed by FCSO to tell our members to bill bilateral blepharoplasty procedures and other eyelid procedures on one detail line with modifier 50 and a QB of 1(quantity billed).  When billed on one detail line with Mod 50 and QB 1, claims should pay.

First Coast is working on this issue which is affecting all ophthalmic procedures that can be billed bilaterally.  First Coast’s Provider Outreach and Education team may be publishing an official article on this issue.  First Coast has been in contact with CMS to let them know of the issue.  Hopefully, CMS will realize that this may be a bigger issue than they expected and will jump on getting a fix in place. 




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