Five great facts you should know about coding for punctal plugs.
Suzanne Corcoran, C.O.E.
Medicare coverage of punctum plugs continues to raise questions in many optometrists' minds. This month, I'll discuss some of the nuances of reimbursement for receiving this procedure.
Does Medicare cover punctal occlusion with punctal plugs?
Answer: Yes. CPT code 68761 (closure of lacrimal
punctum; by plug, each) describes the professional service. The code is the same whether you're inserting collagen or silicone plugs. As of this year, there's no separate payment for supply of the plugs.
What documentation does Medicare require to support this procedure?
Answer: The procedure for which you code 68761 is minor surgery. The standard of care for the treatment of dry eyes entails an initial trial with topical medications such as artificial tears or anti-inflammatory agents.
Medicare doesn't expect you to perform surgery as an initial treatment, so you'll want to document that you tried medical therapies that failed before you plan to perform punctal occlusion.
Your chart documentation should state that you reviewed the risks and benefits of and alternatives to surgery with the patient before you performed the procedure and that you obtained the patient's consent.
Also be sure to record any preoperative procedures, such as anesthetic drops. Note the brand, size and lot number of the plugs, which punctum you occluded, and any other postoperative instructions you feel are important.
How should I submit the claim?
Answer: Medicare uses special "E" modifiers to identify which puncta you treated. Use one claim line per punctum and append the appropriate E modifier:
- E1 -- Left upper lid
- E2 -- Left lower lid
- E3 -- Right upper lid
- E4 -- Right lower lid.
Punctal occlusion is subject to Medicare's multiple surgery rules. The second line (and 3rd and 4th if applicable) also uses modifier 51.
For example, if you occluded both lower
puncta, then the claim would look like this:
Some Medicare carriers have issued different instructions. If that's the case in your area, then follow your carrier's instructions in this instance.
Also, be aware that commercial carriers usually don't recognize "E" modifiers.
Is an exam payable on the same day?
Sometimes. Code 68761 has a 10-day global period. You may charge an exam when you perform a separately identifiable service. Determination of the need for the procedure would qualify as a "separately identifiable service." Also, treatment of other, unrelated conditions would justify reimbursement for the exam. Add modifier 25 to the visit code.
What is Medicare reimbursement for this procedure?
Answer: The national Medicare participating allowable in 2002 is $163.26. For non-participating
O.D.s, the allowable is $155.10 and the limiting charge is $178.37. These amounts are adjusted by local wage indices in each area. The full allowable is applied to the first procedure; the value of the subsequent procedures is reduced by 50%.
Special Note: Optometrists' scopes of practice vary by state, and some procedures aren't permitted in some areas. Medicare will only cover services that the optometrist is licensed to perform.
SUZANNE CORCORAN IS VICE PRESIDENT OF CORCORAN CONSULTING GROUP. REACH HER AT (800) 399-6565 OR AT
Optometric Management, Issue: September 2002