Optometry Coding & Billing Alert

Question: We use both temporary and permanent punctal plugs. Should I code differently for each type?

California Subscriber

Answer: You should use 68761 (Closure of the lacrimal punctum; by plug, each) for punctal plug insertion, regardless of type. Your optometrist may use three types of punctal plugs: temporary collagen, semipermanent silicone, and intracanalicular plugs. For Medicare claims, you should append the E modifiers to the procedural code to explain the plug's location. Use modifier E1 (Upper left lid), E2 (Lower left lid), E3 (Upper right lid), or E4 (Lower right lid) depending on where the optometrist has to place 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).

Supplies: Don't expect payment for punctal plug supplies from Medicare -- which, unfortunately, considers the plugs non-billable.

Non-Medicare carriers, however, may pay for the plug supply. Depending on the type of plug, you'll report 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]).

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