Ophthalmology and Optometry Coding Alert

Placing punctal plugs (implants which help to keep the cornea moist by blocking the punctum -- the entrance to the tear drainage system), requires careful coding in order to get reimbursed adequately for the procedure and the supply. We talked to two coders about the best ways to most adequately bill for the procedure and supplies.

There are two kinds of punctal plugs: permanent, which are made of silicone, and temporary, which are made of collagen. No one reimburses for the temporary punctal plugs, according to Tracy Copeland, insurance specialist with Thomas Larkin, MD and Associates, a two-ophthalmologist, two-optometrist practice in Denver, CO. The correct HCPCS code for the permanent version is A4263 (permanent, long-term, non-dissolvable lacrimal duct implant, each). The HCPCS code for the temporary (collagen) plug is A4262 (temporary, absorbable lacrimal duct implant, each) -- but dont expect to get paid.

It is essential that you use the correct HCPCS code, our sources note. If you file using A4262, and placed the silicone (permanent) plug, you will not be paid the $70 or so the plug costs you. And as will be seen below, sometimes the pay-up for the supply is better than the procedure reimbursement, so take the HCPCS codes seriously.

Both HCPCS and CPT Codes Important to Adequately Get Paid

Commercial carriers pay well for the supply, but not for the procedure, while Medicare pays well for the procedure, but not for the materials, Copeland says. So to have all your bases covered, make sure you are charging both supply and procedure codes properly.

First of all, always report the supply current to the implant procedure, which is 68761 (closure of the lacrimal punctum; by plug, each). The next question is whether to use the -50 modifier (bilateral procedure, at the same operative session), -RT (right eye) and -LT (left eye), or the E series (level II, HCPCS/National modifiers).

We do get paid for doing punctal plugs, but we dont get paid correctly all the time, says Copeland. The biller explains that every insurance company has its own system for reimbursing for this procedure (and the supply). Everybody pays all over the place, as she puts it. So you have to code the way they want you to.
Copeland uses the -50 modifier for both Medicare and commercial payers. If you do both eyes, our Medicare carrier likes the -50 modifier, she says. And in our geographic area, I think the -50 modifier works best for commercial payers too. Therefore, you would code the procedure 68761-50, and get paid twice -- to cover both eyes.

Angela Spurlin, insurance manager for Jacksonville Eye Clinic, a solo ophthalmologist in Jacksonville, NC, uses the E-series of modifiers to distinguish where the plugs were put. There could be four plugs, not just two, she says. The E series are as follows:

E1 designates the left upper lid
E2 the left lower
E3 the right upper
E4 the right lower

You can use any combination of these, and in theory get paid for each plug and each procedure, she notes. So, you could get paid four times, if you placed four plugs at one session. In practice, however, this is rarely done, says Spurlin. We usually put one plug in first, to see if it works, she says. Then the patient comes back, and we do the other.

Note: E series codes are only for Medicare; commercial payers dont recognize them. This is a shame, because they are so location specific, as the punctal plug scenario shows.

With commercial (non-Medicare) carriers, you may have to use the -51 modifier instead of -- or in addition to -- the -50 modifier. The -51 modifier is for multiple procedures. For example, if you insert a punctal plug in the lower and upper puncta of the same eye, you would code 68761 (closure of the lacrimal punctum by plug, each) on the first line, and 68761-51 on the second line; the -50 modifier would not be appropriate in this case because it is not a bilateral procedure.

Also, be aware that many commercial payers systems are set up to recognize the -51 modifier as a reduction, so for them, you will have to use separate lines. Lets say you insert all four punctal plugs in one session. You would have four lines: 68761 on the first line, 68761-51 on the second line, 68761-51 on the third line, and 68761-51 on the fourth line. You may well find that you need to send a cover letter to the insurance company explaining the anatomical facts (i.e. the patient has four puncta, and you placed four punctal plugs).