Ophthalmology and Optometry Coding Alert

Many ophthalmologists are confused about how to code for removing punctal plugs, or for reinserting them. The patients may rub them and lose them and want them replaced, or may want them removed altogether. Sometimes the changes must be made shortly after the plugs are inserted; sometimes there is a time lag. The most important thing to remember about punctal plugs (68761) is that the global postoperative period is short: 10 days. It is not, as many ophthalmologists think, 90 days.

1. Removal. There is no appropriate way to charge in the Medicare program for removal of plugs, says Lise Roberts, vice president of Health Care Compliance Strategies Inc., a healthcare compliance consulting company based in Jericho, N.Y. This is true whether the removal is done by the surgeon who placed them, or by someone else, says Roberts. Medicare considers that if there is no specific code in CPT for the removal of a suture or implanted device, then the removal is included in the global package of insertion, regardless of the timing of the removal. If it is someone other than the implanting surgeon that is doing the removal, Medicare believes the service should be coded as a level of care office visit.

2. Reinsertion. If plugs need to be replaced within the 10-day global period, you should use 68761 with the -78 modifier (return to the operating room for a related procedure during the postoperative period) because the replacement is due to a complication. After the global period is up, you can code 68761.

3. Temporary or permanent plugs. What if you place temporary punctal plugs during the first procedure, the patient gets relief with the temporary plugs, and then the permanent ones are implanted within the 10-day global period? You would have to code using the -58 modifier (staged or related procedure or service by the same physician during the postoperative period) because this is now a planned, staged procedure. If, however, you make the change after the global period has expired, you can bill 68761.

Tip: Remember if you use temporary plugs (collagen), you cannot charge for the supply. If you use permanent plugs (silicone), you can using the code A4263.

Note: For more on punctal plugs, see the article in Ophthalmology Coding Alert for August 1999, Modifiers
are the Key to Getting Paid for Multiple Punctum Plugs.