Optometry Coding & Billing Alert

Stress the importance of medical necessity in the documentation

When the optometrist decides to place punctal plugs, choosing the procedure code seems easy because you only have one code to use. But if you don't apply the correct modifiers or provide medical necessity in the provider'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 CPT Code Based on Plug Type

There are three types of punctal plugs that your optometrist may use: temporary collagen, semipermanent silicone, and intracanalicular 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, says Dolores Berkery, practice manager of Gold Ophthalmologic Associates PC in Great Barrington, Mass.

Tip: Carriers pay close attention to whether punctal plugs are medically necessary. The optometrist's documentation should show that your provider first tried other treatments, such as eye drops or ointments, and that they failed, Berkery says.

2. Use Modifiers to Indicate Anatomical Location

For Medicare claims, you should append the E modifiers to the procedural code to explain 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 optometrist 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 optometrist 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 modifier 51 (Multiple procedures) depending on your carrier. You-ll be subject to multiple-procedure reimbursement reductions on the second, third and/or fourth procedures.

Example: The optometrist 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 are not billable separately anymore for Medicare and most private carriers,- says Loetta Morales, insurance specialist at Gorovoy Eye Specialists in Fort Myers, Fla.

Non-Medicare carriers, 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) for some carriers. Still other carriers 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]).