Ophthalmology and Optometry Coding Alert

Hint: Modifier -50 won't get all 2-plug claims paid

Modifiers pose the greatest difficulty when coding for punctum plugs. Navigate the hazards with this coding map.

Ophthalmologists insert punctum plugs - 68761 (Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery; by plug, each) - to combat dry eye syndrome (375.15). Each eye has two puncta (tear drainage openings). When the openings are plugged, the eye's natural moisture stays in the eye longer.

Append Modifier -50 for One Plug Per Eye

In the past, some coders have mistakenly used modifier -50 (Bilateral procedure) when their ophthalmologist inserts multiple plugs in a single surgical session. And modifier -50 allows you to bill for inserting a plug in each eye, says Nancy Spink, insurance specialist at Anderson & Shapiro Eye Surgeons in Madison, Wis. By definition, a bilateral procedure is one in which a physician performs the same service on two separate sides of the body, such as inserting a punctum plug in both the left and right eye, not inserting two plugs in the same eye.

Turn to -51 for 2 Plugs in One Eye

When your ophthalmologist inserts multiple plugs in a single eye, you should append modifier -51 (Multiple procedures) - instead of modifier -50 - to 68761. You should also indicate the lid in which the physician inserted the plug using the E modifier: E1 (Upper left eyelid), E2 (Lower left eyelid), E3 (Upper right eyelid), and E4 (Lower right eyelid). Be aggressive regarding billing for each plug. "There are two punctums per eye, and sometimes insurance companies may bundle those together, when in fact you can bill out each individual insertion of a punctum plug," says Cindy Schroeder, CPC, CPC-H, LPN, of Merit Care Health Systems in Fargo, N.D.

If your carrier doesn't bundle eye procedures together, follow this example: Patient A complains of dry, irritated eyes (375.15). The ophthalmologist inserts a plug in the puncta of her right and left lower eyelids. You should report 68761-E2 (1 unit) on the first line of the claim and 68761-51-E4 (1 unit) on the second line of the claim. Most carriers will reimburse you 100 percent of the fee for the first insertion and 50 percent of the fee for the second service. Don't substitute modifiers -LT (Left side) and -RT (Right side) for the E modifiers, which are more specific.

Make Medicare Pay Up for Both Lines

According to Medicare's multiple-procedure payment rule, the first procedure should be paid at 100 percent of the fee schedule, and procedures two-four are reimbursed at 50 percent.

When billing on two lines, for the first line the carrier paid 68761-50 at 150 percent of the fee schedule, and reimbursed the second line at half of 150 percent.

If you're still billing with the two-line method, review your Medicare Explanation of Benefits (EOB), to ensure that you are receiving the correct payment.

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