Ophthalmology and Optometry Coding Alert

Rely on documentation and modifier -58 for permanent implant payment

If you insert permanent plugs within the global period for a temporary plug insertion, providers may scoff at reimbursement for the second procedure - unless you have the necessary documentation for modifier -58 (Staged or related procedure or service by the same physician during the postoperative period).

Generally, an ophthalmologist will insert temporary collagen implants to determine if a plug is an appropriate treatment for a patient's condition, typically dry eye syndrome (375.15). If the temporary plug works, an ophthalmologist will then insert a permanent silicone plug.

The global period for the initial temporary punctal plug closure (68761) is 10 days, so for full reimbursement, you should wait until the global period has ended before inserting the permanent plug (unless of course medical necessity requires you do it earlier), says Cindy Schroeder, CPC, CPC-H, LPN, of Merit Care Health Systems in Fargo, N.D.

"It normally takes at least that long (10 days) to know if they are working," adds Nancy Spink, insurance specialist at Anderson & Shapiro Eye Surgeons in Madison, Wis.

But things get tricky when an ophthalmologist decides not to wait until the global period has expired before inserting the permanent plugs.

If the ophthalmologist performs the permanent implant procedure (coded 68761 - the same as the temporary procedure) within the 10-day global, carriers will deny reimbursement for the procedure by including the service in the global surgical package.

Consider Your Modifier Options

Some coders append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to indicate to the carrier that the ophthalmologist performed a related subsequent procedure within the global of another procedure. The second procedure must involve a return to the "operating room."

Ophthalmologists do not insert punctum plugs in what Medicare considers an "operating room" setting, so reporting this modifier is incorrect coding.

You could use modifier -58, however, if the ophthalmologist documents in her notes from the previous temporary procedure that she "planned" on placing the permanent, silicone plugs.

Swallow Plug Costs for Medicare Carriers

Medicare and some private carriers bundle payment for both the temporary collagen implant (A4262, Temporary, absorbable lacrimal duct implant, each) and the permanent silicone plug (A4263, Permanent, long-term, nondissolvable lacrimal duct implant, each) into the fee for the procedure (68761).

In Mississippi, for example, Medicare includes the cost of the plug in the procedure, says Nancy Cockrell, insurance and billing coordinator at Jackson Eye Associates in Mississippi. In fact, all carriers do.

When billing a payer other than Medicare, you can attempt to bill the supply item with 99070, Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided), says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

When using code 99070, list the item in the comments area or Box 19 of your claim form and include an invoice listing the cost of the item.