Ophthalmology and Optometry Coding Alert

Many ophthalmologists wonder if they can bill 68801* (dilation of lacrimal punctum, with or without irrigation) and 68810* (probing of nasolacrimal duct, with or without irrigation) at the same time. They think it may be possible since they dilated the punctum and also probed the duct. But ophtalmologists cannot bill both codes because the dilation is included in the probing code.

Dilation is accomplished by the use of probes of increasing size, which enlarge the lacrimal punctum, making it possible for tears from the lacrimal gland to drain through the punctum. Probing involves dilation and then threading a probe along the canaliculus to the lacrimal sac. Probing is usually done under local anesthesia. If the probing is done under general anesthesia, as is sometimes required, you should code 68811 (requiring general anesthesia).

The fee for the probing includes the fee for the dilation, so if you bill for both, you will be denied payment for 68801.

You cant bill both 68801 and 68810, says Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care, a 10-ophthalmologist practice in Louisville. To get the probe in, you have to dilatethe dilation is included in the probing. Insurance payers believe that if one minor part of what you have done is necessary in order to do the main procedure to fix the problem, then the minor part is included in the main procedure and is not separately billable. For this reason, 68801 is bundled into 68810 in the Correct Coding Initiative (CCI) for Medicare billing. This would be true for private payers as well, says Oyler. Most claim filing systems are set up with edit programs very similar to the CCI program, she says. Due to an oversight, the CCI does not bundle 68801 into 68811, although many private payers do bundle the two codes.