Ophthalmology and Optometry Coding Alert

It is a uniquely ophthalmological situation: There are two eyes, and each eye has two ducts (puncta). Therefore, coding for punctum plug procedures will depend on how many plugs are placed. Although there are different ways to code, some payers do have their preferences.

Permanent punctum plugs are expensive: about $70 each (silicone). The procedure code is 68761 (closure of the lacrimal punctum; by plug, each) and has a reimbursement of $141 to $167, according to the HealthCare Consultants 1999 Physicians Fee & Coding Guide. If you place only one plug, the coding is fairly simple. But if you place more than one, watch out. Different payers have different requirements. If you are using modifier -50 (bilateral procedure), and thats not working, you may need to be using modifier 51 (multiple procedures). Likewise, if modifier -51 isnt working for a payer, you may need to try modifier -50. You might even need to use both. It depends partly on where you are in the country, whether the payer is Medicare or commercial, and what their computer system happens to like.

Know Your Modifier Options: E, -50, and -51

But before you even know your insurance company preferences, you have some options. Because 68761 is a unilateral procedure, if you place a plug in two separate eyes (two plugs total), you could use modifier -50. But if you place two plugs in one eye, you could not use modifier -50, since that is not a bilateral procedure; instead, you would have to use modifier -51, indicating that this is for multiple procedures. And then there are the E modifiers, which indicate which duct, out of the possible four, is being closed.

The E codes are as follows: E1 (upper left eyelid), E2 (lower left eyelid), E3 (upper right eyelid), and E4 (lower right eyelid). If you are already using these modifiers to bill the silicone plugs supplied, you should continue to use them, says Stephanie Habte, accounts receivable and coding manager for Clarity Health Corporation, a New York City company which manages 11 ophthalmology practices. If you are not, get started and receive proper reimbursement for all the closure procedures.

This combination of modifiers can get very complicated. Thats why Habte chooses to use modifier -51 when appropriate. This modifier is used when multiple procedures, other than Evaluation and Management (E/M) services, are performed at the same session by the same provider, and the primary procedure or service may be reported as listed. The additional procedure or service may be identified by appending modifier -51 to the additional procedure or service code, explains Habte. This is the appropriate modifier to use for coding more than one punctum plug, she continues. It should be appended to code 68761. When using modifier -51, enter the code (68761) separately, with the -51 to indicate that it was done more than oncethat it is not being billed more than once erroneously.

As a multiple procedure, this modifier covers more than one plug, whether they are placed in one or both eyes. Except for payers who insist that only one line be used on the claim form, you can use modifier -51, and the E codes, to get paid for multiple punctum plugs, says Habte. (For more information on one-line billing, see page 59.)

When we do two or more plugs and bill for the
silicone ones, we usually get paid for the first one, but the others are denied as a duplicate charge, says Laura Osborn, billing clerk for Daytona Ophthalmic services, a two-ophthalmologist practice based in Daytona Beach, FL. We use the E codes and modifier -50. Is there another way to bill for the silicone plugs? she asks.

The answer is yes. Modifier -50 identifies a procedure performed identically on the other side of the body. Modifier -51 is preferable (unless the carrier requires you to use only one line, as mentioned earlier), because the procedure may not be a strictly bilateral one. For example, the upper left eyelid and the lower right eyelid may have each gotten a plug. While this affects both eyes, it is not bilateral in the literal sense. If both the upper left and the upper right eyelids got plugs, that would be bilateral.

Overcome Reimbursement Challenges

Regardless of which modifier you use, you will not be paid your full fee from Medicare for the second, third, or fourth plugsinstead, you will get 50 percent of your fee each additional time for 68761 (according to the Healthcare Consultants 1999 Physicians Fee and Coding Guide). For the first plug, however, you will receive 100 percent payment. Your fee is important, especially if you are billing a payer who requires you to use only one line.

Note: Medicare carriers compare 50 percent of their fee schedule to 100 percent of the charge submitted. With Medicare (typically the largest portion of the patient population in an ophthalmology practice) there is no point to carrying an inflated accounts receivable on the books. The reduction can safely be made on your claim. With some commercial payers, however, the biller should not make the reduction in charges for the secondary procedures as it may be discounted by 50 percent on the reduced rate.

Coding Examples Here are examples of how to code placement of punctal plugs, with the CPT code, the units, and the fee. (You will have to fill in your own fees and supply costs.) Example 1: One silicone plug in lower left eyelid: Line 1: 68761-E2 (1 unit) (100 percent of fee for 68761) Line 2: A4263 (1 unit) (cost of plug) Example 2: One silicone plug in lower left eyelid, one silicone plug in lower right eyelid: Line 1: 68761-E2 (1 unit) (100 percent of fee for 68761) Line 2: 68761-51-E4 (1 unit) (50 percent of fee for 68761) Line 3: A4263 (2 units) (cost of plug multiplied by two) Example 3: One silicone plug in upper left eyelid, one silicone plug in lower left eyelid, one silicone plug in lower right eyelid: Line 1: 68761-E1 (1 unit) (100 percent of fee for 68761) Line 2: 68761-51-E2 (1 unit) (50 percent of fee for 68761) Line 3: 68761-51-E4 (1 unit) (50 percent of fee for 68761) Line 4: A4263 (3 units) (cost of plug multiplied by three) Example 4: One silicone plug in each eyelid: Line 1: 68761-E1 (1 unit) (100 percent of fee for 68761) Line 2: 68761-51-E2 (1 unit) (50 percent of fee for 68761) Line 3: 68761-51-E3 (1 unit) (50 percent of fee for 68761) Line 4: 68761-51-E4 (1 unit) (50 percent of fee for 68761) Line 5: A4263 (4 units) (cost of plug multiplied by four)

Getting Paid for Supplies

Since 1994, Medicare has had a policy of paying for each individual punctum plug. If you are not getting reimbursed for these, you should be. And you also should be getting paid for the silicone plugs themselves, which are costly (about $70 each). In the Medicare program, you must use the correct HCPCS supply code, A4263. Not only should you use A4263 but its important to indicate the number of plugs in the units field if listing all plugs on one line-item. If you are using temporary collagen plugs (A4262), these will be bundled into the payment for the surgery by Medicare carriers. For other payers you should use the CPT supply and material code, 99070.

You dont need to use the -LT and -RT modifiers when you are using the E modifiers, says Habte. The E modifiers identify the side of the body as well as the upper or lower eyelid. She suggests you check with your local carrier to be sure they recognize the E modifiers. If not, find out if they have comparable modifiers or what their guidelines are for billing multiple permanent plugs.

Tip: The E modifiers were added to CPT in the 1999 version, so all payers, including commercial, should recognize them by now.

One Line Coding Tips

For some payers, you may only be allowed to bill using one line if the procedure is performed bilaterally. In that case, you would use modifier -50, indicating that the procedure is bilateral. Check with your local Medicare carrier to find out how many units you should use. (Some want one in the unit field because their computer system is set up to drive the allowable fee calculation from the modifier field, while others want two in the unit field because their computer is set up to drive the allowable fee from the unit field.) You would calculate your fee based on how many puncta are closed. For example, if you place one plug in each eye, and your fee is $100, you would code 68761-50, 1 (two units), and $150. If you place plugs in the upper and lower puncta of one eye, however, you would have to use two line items and code 68761-E(_), one unit, and $100 on the first line, and 68761-51-E(_), one unit, and $50 on the second line.

Local Carrier Rules May Vary

Usually, Medicare requires only one line be used if the same procedure is being performed two or more times. However, for punctum plugs, this is not a ruleyou can use modifier -51 and several lines. You have to find out the rules and regulations of your local carrier, Habte stresses.

And dont forget Medicaid and commercial payers as well. In Habtes area, Medicaid doesnt accept modifier -50 for any office procedures at all. But they might accept it for punctum plugs, because this is similar to surgery, she says. So you need to find out how they want you to file
the claims.

Sometimes a carrier will tell you to file these on paper, says Habte. If theres an iffy case, you should contact your provider relations representative. Its very important to find out who that person is, she explains. And when you do get information on how to document, make sure you get it in writing. The first person you talk with will tell you one thing, and the second one will tell you another, says Habte. So I will request that they fax me a copy or mail me a copy.

Catherine Brink, CMM, CPC, president of Healthcare Resource Management in Spring Lake, NJ, agrees with the idea of staying in touch with carriers. And the consultant adds that you should avoid electronic filing in cases like this. If there are any questions about how something will be paid, I wouldnt send it electronically, she says. Instead, just send a paper claim from the beginningand send the notes, too.