Ophthalmology and Optometry Coding Alert

Question: Current coding uses the -E1 to -E4 codes with 68761 (closure of the lacrimal punctum; by plug, each), 68801* (dilation of lacrimal punctum, with or without irrigation), and A4263 (permanent, long-term, nondissolvable lacrimal duct implant, each). When an office visit is coded with punctal plug service and more than one plug is inserted (usual case), this forces more than six entries on the HCFA form and results in a split claim. When filed electronically (usual case), many if not most payers arent able to link the two claim pieces together and deny one set of codes as dupes. This forces appeals to correct their mistake, which ultimately gets paid, but its a lot of work. Has anyone had success using the -50 modifier (bilateral procedure) and/or units of two to four with plugs? Medicare says they dont need any modifiers, but I dont trust them to process correctly when more than two plugs are inserted.

Anonymous California Subscriber

Answer: Many coders are curious about how to fit multiple punctal plug service onto one HCFA claim form. You do need to use the lid modifiers (-E1 for the upper left, -E2 for the lower left, -E3 for the upper right, and -E4 for the lower right) with 68761. For the silicone plugs, which use the supply code A4263, you should definitely use unitsmany Medicare carriers will not pay these any other way. In the case of an office visit (one line-item), closure of all four puncta (four line-items), and four plug supplies (one line-item using 4 in the units field), gives you exactly six lines on the claim form.

Remember that an office visit is only appropriate to code if a separate, identifiable service is documented. This means there must be a history with a minimum of a chief complaint and history of the present illness, an examination, an impression and a plan that indicates as one component the planned procedure to address the diagnostic problem.

A separate, dated entry should be made for the procedures with a brief description of them, how the patient tolerated them, and the patients disposition following them. This does not have to be a dictated operative report, but can be entered in the progress notes by hand.

If you need to perform 68801* in addition, you will indeed run over onto a second form. However, 68801* should not be coded in addition to plug closure. Dilation is described in the literature as a necessary part of the procedure to implant the plugs and is integral to the performance of plug closure. Unfortunately, these two codes are not bundled in the Correct Coding Initiative (CCI), so people do bill them. The problem is that if they are audited, and the auditor determines that the dilation is part of the procedure of insertion, then the physician doesnt have a leg to stand on.

According to the CCI and CPT, if a lesser procedure must be performed in order to accomplish the larger planned procedure, the lesser procedure is considered incidental to the larger procedure and is not separately billable. The coders who are trying to bill 68801* and 68761 would then have a much bigger problem on their hands than split claims. At the very least, the money would have to be paid back.

Sources for answers to You Be the Coder and Reader Questions: Lise Roberts, vice president, Health Care Compliance Strategies, Syosset, N.Y.; Heather Freeland, consultant, Rose and Associates, Duncanville, Texas; Ramona Cosme, president, Ramco Medical Billing, Edison, N.J.; Kitty Timmes, COMT, office manager, Joseph J. Timmes, Jr., MD, FACS, Annandale, Va.; Lois Carr, surgery coordinator/reimbursements, University of Tennessee Medical Group, Ophthalmology; Robin M. Fox, HCRM, director of reimbursement for Eye Centers of Florida, Ft. Myers, Fla.