Ophthalmology and Optometry Coding Alert

Successfully billing multiple procedures on eyelids depends on using the correct modifiers based on the type of procedure and the lids involved. You have a choice of Modifier 50 (bilateral procedure), -51 (multiple procedures), or -E1 to -E4 (the eyelid modifiers). The E modifiers are the most useful because they link the procedure to a specific eyelid. However, sometimes the E modifiers are not as appropriate as modifier -50 or -51.
Punctal Plugs and Punctal Dilation
Punctal-plug closure is a unilateral procedure. For most payers, you can bill for two lids by using modifier -50 if the same procedure is done on both eyes. For example, if the lower left and lower right puncta are closed with plugs, bill 68761 (closure of the lacrimal punctum; by plug, each) on two lines, with modifier -50 appended to the second. Also, it's a good idea to append the eyelid modifier (-E1 [upper left, eyelid], -E2 [lower left, eyelid], -E3 [upper right, eyelid], or -E4 [lower right, eyelid]) to indicate which lid the procedure is performed on. For Medicare, bill using one line for two lids, with modifier -50 appended (e.g., 68761-50) without the E modifiers.
 
If all four puncta are plugged, use modifier -51 and the eyelid modifiers instead of modifier -50. Billing simply 68761-50 will result in payment for two plug insertions, not four. Bill four-punctal plug procedures on a claim form as follows:
 
Line 1: 68761-E1 
Line 2: 68761-51-E2 
Line 3: 68761-51-E3 
Line 4: 68761-51-E4.
Medicare will pay 100 percent for the first procedure and 50 percent for each of the other three.
Lesion Removal
Lesion-removal codes (11440-11446), although unilateral, should not be billed with modifier -50 when performed on both eyes. Whether two lesions are removed from one lid, or one lesion from one and one from another, there are still two lesions: Count the lesions, whether they are on one or both eyes.
 
Contact your carriers for their rules on coding multiple lesion removal. Some want you to use modifier -51 or the eyelid modifiers. Some want both. Two examples demonstrate how a claim for multiple lesion removal should read:
 
1. A patient with a 0.4-cm benign lesion on the upper eyelid of the right eye and the lower eyelid of the left eye:
 
Line 1: 11440-E3 
Line 2: 11440-51-E2.
2. A patient with a 0.4- and a 0.7-cm benign lesion on the upper right eyelid:
 
Line 1: 11441-E3 
Line 2: 11440-51-E3.
 
Note: Always list the procedure with the highest reimbursement first when billing multiple procedures because that one is reimbursed at 100 percent.
Alternatively, you can bill 67840* (excision of lesion of eyelid [except chalazion] without closure or with simple direct closure). Use 67840* when the lesion involves more than skin, such as the lid [...]