Ophthalmology and Optometry Coding Alert

Question: How do we bill for the placement of punctal plugs in all four eyelids in a patient insured by North Carolina Medicaid? When multiple plugs are placed, is each paid at 100 percent? What about Medicare?

AAPC Forum Participant

Answer: When reporting punctal plugs, check with the payer to verify their reporting requirements for 68761 (Closure of the lacrimal punctum; by plug, each), as modifier preferences may vary.

North Carolina Medicaid requires that you bill claims for 68761 with the following modifiers:

• E1 (Upper left, eyelid)
• E2 (Lower left, eyelid)
• E3 (Upper right, eyelid)
• E4 (Lower right, eyelid)

Its guidance goes on to state that, in cases where your physician places multiple punctal plugs during an encounter, you must bill each subsequent eyelid with modifier 51 (Multiple procedures) for the claim to process correctly. And when more than one punctum is occluded at the same time, multiple surgery rules apply — the first procedure is allowed at 100 percent, and each additional procedure is allowed at 50 percent (https://medicaid.ncdhhs.gov/blog/2022/01/18/closure-tear-duct-using-plug-cpt-code-68761-billing-guidelines)

Note: Each Medicaid plan may have different requirements.

On the other hand, Medicare will first assign the bilateral payment rules, then the multiple procedure rules — each applying a 50 percent reduction.

For the two upper lid plugs, the bilateral procedure rule applies: one is paid in full, and one is reduced by 50 percent. For the two lower lid plugs, the same bilateral procedure rule applies, so one is paid in full, and one is reduced by 50 percent. Then, the multiple procedure payment rule applies, and the 150 percent calculated for the lower lids is further reduced by 50 percent, with the 75 percent divided between the two eyes; resulting in:

• 68761-E2 pays 100 percent allowable
• 68761-E4 51 pays 50 percent allowable
• 68761-E1 51 pays 37.5 percent allowable
• 68761-E3 51 pays 37.5 percent allowable