Optometry Coding & Billing Alert

Hint: Modifier -50 won't get all 2-plug claims paid

Modifiers pose the greatest difficulty when coding for punctum plugs. Avoid appeals and audits with this billing map for 68761.

Punctum plugs combat dry-eye syndrome (375.15, Tear film insufficiency, unspecified). When the openings are plugged -- 68761 (Closure of the lacrimal punctum; by plug, each) -- the eye's natural moisture stays in the eye longer.

When an optometrist places a plug in each eye, make sure you submit your claims with modifier -50 (Bilateral procedure) because this service is valued as a unilateral code -- but don't use this same modifier for multiple plugs inserted in a single eye. By definition, a bilateral procedure is one in which a physician performs the same service on two separate sides of the body, such as inserting a punctum plug in both the left and right eye, not inserting two plugs in the same eye.

Turn to -51 for 2 Plugs in 1 Eye

When an optometrist inserts multiple plugs in a single eye, make sure your claims use modifier -51 (Multiple procedures) instead of modifier -50. Medicare and Blue Cross Blue Shield of North Carolina have consistently paid for 68761 submitted with modifier -50 for plugs in separate eyes and -51 for multiple plugs in a single eye, says Robin Hawley, insurance manager at Chapel Hill Eye Care Center in North Carolina.

Make sure your claims also make use of the eye modifiers to indicate the lids in which the optometrist inserted each of the plugs: E1 (Upper left, eyelid), E2 (Lower left, eyelid), E3 (Upper right, eyelid), and E4 (Lower right, eyelid).

Be aggressive regarding billing for each eye. "There are two punctums per eye, and sometimes insurance companies may bundle those together, when in fact you can bill out each individual insertion of a punctum plug," says Cindy Schroeder, CPC, CPC-H, LPN, of Merit Care Health Systems in Fargo, N.D.

If your carrier doesn't bundle eye procedures together, follow this example: Patient A complains of dry, irritated eyes (375.15). The optometrist inserts a plug in the puncta of her right and left lower eyelids. You submit a claim with one unit of 68761-E2 on the first line and one unit of 68761-51-E4 on the second line. Most carriers will reimburse you 100 percent of the fee for the first insertion and 50 percent of the fee for the second service.

Make sure your 68761 claims do not substitute modifiers -LT (Left side) and -RT (Right side) for the E modifiers, which are more specific.

Make Medicare Pay Up for Both Lines

Prior to March 1998, Medicare carriers instructed providers to submit two lines to bill for four lids: 68761-50 (bilateral plug closure) and 68761-50-51 (bilateral and multiple plug closure). The problem with that billing method is that some Medicare carriers were not processing payment correctly.

According to Medicare's multiple-procedure payment rule, the first procedure should be paid at 100 percent of the fee schedule (about $127), and procedures two-four are reimbursed at 50 percent of the fee schedule (about $63.50 each). When billing on two lines, for the first line the carrier paid 68761-50 at 150 percent of the fee schedule (about $190), and reimbursed the second line at half of 150 percent (about $95) (all fees are based on nonfacility relative value units).

If you are still billing with the two-line instead of the four-line method, review your Medicare Explanation of Benefits (EOB), to ensure that you are receiving the correct payment.

Some carriers still use the two-line method, so "We bill the procedure 67861 on two separate lines," says Joanne Halcromb, billing supervisor at Ponderosa Vision Clinic in Aurora, Colo.

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