Ophthalmology and Optometry Coding Alert

Tip: Stress the importance of medical necessity in the documentation to your ophthalmologist.

When the ophthalmologist decides to place punctal plugs, choosing the procedure code seems easy because you only have one code to choose from. But if you don't apply the correct modifiers or provide medical necessity in the physician's documentation, you can kiss your reimbursement goodbye. Follow these three simple steps to guarantee you'll see payment on each plug placement procedure.

1. Don't Change Procedure Code Based on Plug Type

There are three types of punctal plugs that your ophthalmologist may use: temporary collagen, semipermanent silicone, and intra-canalicular plugs. How you code the plug placement doesn't change based on the type of plug.

You should use 68761 (Closure of the lacrimal punctum; by plug, each) for punctal plug insertion, regardless of type. There is no code for removal of plugs, notes David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

Tip: Carriers pay close attention to whether punctal plugs are medically necessary. The ophthalmologist's documentation should show that your physician tried other treatments, such as eye drops or ointments, first and that the more conservative treatments failed.

2. Use Modifiers to Indicate Anatomical Location

For Medicare claims, you should append the E modifiers to the procedural code to indicate the plug's location. Append E1 (Upper left lid), E2 (Lower left lid), E3 (Upper right lid), or E4 (lower right lid) depending on where the ophthalmologist placed the punctal plug.

Alternative: Most non-Medicare carriers do not recognize the E modifiers. Instead, you can use modifiers RT (Right side) and LT (Left side).

Good news: If your ophthalmologist places more than one plug during the same procedural session, you can report each placement. You may need to append modifier 50 (Bilateral procedure) or report the procedure twice on two separate claim lines [line one with 68761-RT and line two with 68761-51- LT]. You'll be subject to multiple-procedure reimbursement reductions on the second eye.

The ophthalmologist places silicone plugs into a Medicare patient's two lower puncta. You would report 68761-E2 and 68761-E4. You'll be paid at 100 percent for the first plug placement and 50 percent for the second.

3. Report Supply Based on Carrier

Don't expect payment for punctal plug supplies from Medicare.

The plugs have not been billable separately to Medicare and most local carriers for the last several years, explains Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Best Practices- Network Operations at Mount Sinai Hospital in New York City.

Non-Medicare payers, however, may pay for the plug supply. Depending on the type of plug, you'll report HCPCS code A4262 (Temporary, absorbable lacrimal duct implant, each) or A4263 (Permanent, long-term, nondissolvable lacrimal duct implant, each). Still other payers may prefer 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]).