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. [...]