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Medicare bans Cosmetic Upper Eyelid Surgery when a medical necessary one is being performed (Even i

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backrow

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I was confused for a bit because I thought they were a Ft Collins eyelid surgeon ;)

And Medicare doesn't make procedures illegal, they simply say what they pay or won't pay.


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MstaKing10

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Bundling procedures is a cost cutting scheme employed by Medicare and other insurance companies and I really don't see it stopping anytime soon
 

thiaeyemd

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That is not true. A couple years ago they bundled functional blepharoplasty with functional ptosis but as of July 1 2016 a cosmetic upper eyelid blepharoplasty cannot be done with a medicare functional ptosis. It is literally illegal for the surgeon to do so and subjects them to potential criminal prosecution, fines and/or prison. Ask your oculoplastics attendings, it is the first time that an elective procedure has been "outlawed" to be done at the same time as functional procedure. Read page 2.


https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/Downloads/MM9658.pdf
 
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Why not quote the CMS page in the first post instead of some commercial website? To me that just reeks of subtle advertisement.

And the link you provided, in my read of it, does not outlaw doing both at the same time, it says you can't bill for the BULB when doing ptosis surgery and that any eyelid skin removal is considered part of the ptosis surgery.

Now, if we want to argue the point that you should be able to charge for that portion of the surgery while CMS pays for the ptosis portion then that is absolutely debatable. (or maybe I can't read and messed up the interpretation of the CMS link)


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thiaeyemd

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I didn't have access to the original CMS update until yesterday. I had to get it from an ASOPRS executive member who had it after your previous comment just to make sure there was no misinterpretation.

In regard to the ruling, Reread the ruling. You misread it. It specifically says that you can't charge the patient for a bleph at the same time regardless of cosmetic nature or not. Of course from before you couldn't charge medicare for a functional bleph if they needed a functional ELR for ptosis (because of the bundling) but now the ruling is you can't charge the patient for any bleph even it is cosmetic and even fat removal which as an oculoplastic surgeon I will tell you was never considered part of a functional bleph. On top of that, the statement in there which says that you can't charge for removal of orbital fat implies you can't even do a lower eyelid blepharoplasty at the same time. (ASOPRS is getting clarification on this)

So if a patient comes in with ptosis and needs a levator resection and has only a minimal amount of skin that needs removal with some medial fat that they want removed, it is "illegal" according to medicare for me to perform the ptosis repair and charge them for a cosmetic blepharoplasty (even if they want and are willing to pay for it at the same time). If I do it, I will be legally pursued by CMS and face sanctions, fines and or prison. Yay!

An official letter came out from ASOPRS to all members two weeks ago and then one week ago to warn members not to violate this new ruling as CMS (or the CMS contact that ASOPRS normally uses) has made it very clear that they are going to "go after aggressively" surgeons who violate this rule.
 
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