Ophthalmology and Optometry Coding Alert

Reimbursement for three punctal plug procedures (68761, Closure of the lacrimal punctum; by plug, each) has decreased over the past two years, two because of bundling and one because of a fee schedule reduction.
 
1. A year ago, CCI 7.1 bundled punctal dilation (68801*, Dilation of lacrimal punctum, with or without irrigation) with plug placement (68761).
 
2. The Medicare Fee Schedule for 2002 reduced the fee for 68761 because of a pre-existing error that paid an extra $89 for bipolar cautery (not performed during punctal procedures), $16.50 for a shield, and $15.50 for paper towels, says the American Academy of Ophthalmology.
 
3. Most recently, Medicare deleted all reimbursement for permanent plugs (A4263, Permanent, long-term, nondissolvable lacrimal duct implant, each), "bundling" the supply cost into 68761. Temporary plugs (A4262, Temporary, absorbable lacrimal duct implant, each) are not separately billable either.

Because there was no official announcement from CMS, providers are learning of the plug deletion via notices like the one from Empire Medicare Services, carrier for New York City and surrounding areas. In its January 2002 bulletin, Empire says that the procedure code status for A4263 changed to B, which means "separate payment is no longer made since payment for these medical supplies has been incorporated into the practice expense relative values of individual services."
 
The plug deletion, part of the "Emergency Changes to the 2002 Medicare Physician Fee Schedule Database," was made for reimbursement purposes, says Ramona Cosme, president of Ramco Medical Billing, an ophthalmology coding and reimbursement consultancy based in Edison, N.J.
 
"The bundle isn't in CCI yet, but it will be," Cosme says. "In the meantime, coders have to watch their bulletins to see if it's been deleted as a payable supply."

Providers can bill private payers for punctal plugs and any other supply used during a service with HCPCS codes or 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]). Because the code is nonspecific, include the invoice for the supplies or material. Ophthalmologists can even bill for the temporary plugs by invoice to private payers.
 
"Whichever code you use, you should go ahead and bill private payers for the supply while you can," says John Bell, CEO of Maine Eye Care, Waterville. However, most private companies will probably eventually follow Medicare and not pay for the plugs.