Ophthalmology and Optometry Coding Alert

To optimize reimbursement for punctal plugs ophthalmology coders need to be aware of the difference in supply costs for temporary vs. permanent plugs.

Ophthalmologists will often use collagen, temporary punctal plugs prior to silicone, permanent plugs. This is done to see how well the plugs will work, and, typically, the temporary plugs wont be placed in all four puncta. But the coding and reimbursement scenarios are different for collagen and silicone plugs.

The main difference is in the supply. Medicare and most HMOs pay for the silicone plugs. These are supposed to last 60 to 90 days, and they are expensiveabout $70 each. If a patient needs four plugs, thats $280 for the supply alone. The procedure reimburses well$141 to $167 per punctal closure for 68761 (closure of the lacrimal punctum; by plug, each), according to Healthcare Consultants of Americas 1999 Physicians Fee & Coding Guide.

All of this means that ophthalmologists need to be careful about billing for punctal plugs, says Ramona Cosme, president of Ramco Medical Billing, an ophthalmological billing company based in Edison, N.J. Constantly inserting plugs could create a flag for Medicare, she says. Maybe theyll let you do it once a month on a patient. But they will want to make sure youre not abusing this.

How long should you wait between inserting collagen and silicone plugs? Thats the doctors call, says Cosme. Sometimes the doctor might feel a patient has a bad case of dry eye or keratitis and wants the patient to come back quickly for the permanent plugs. Permanent plugs are expected to last at least three months, she says. They can last indefinitely if the patient doesnt rub their eyes too much or have an anatomical problem with retaining the plugs where they were inserted.

So when you are placing collagen plugs, you should bill 68761 plus the appropriate E modifier or modifiers (E1 for the upper left eyelid, E2 for the lower left eyelid, E3 for the upper right eyelid and E4 for the lower right eyelid). When you are placing silicone plugs you code the same way, with a separate line item for the plug supply code (A4263) and the appropriate number of units for the total number of plugs inserted.

Note that some payers may prefer a one-line billing method if the procedure is bilateral. For these payers, use modifier -50 (bilateral procedure).

Tip: Check with your payer before filing to make sure you know its preferred method.