Optometry Coding & Billing Alert

Question: Can I report an office visit when I insert punctal plugs? How should I do that?


Oklahoma Subscriber

Answer: As long as the punctal plug insertion is not the reason for the office visit, you can report an E/M or eye examination code appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Handle with care: Modifier -25 is on the Office of Inspector General's hit list this year, and overuse of it may make you a more likely audit target. Your records should clearly state the separate reasons for the office visit and the punctal plugs.
 
One clear way of doing this is by documenting two distinct ICD-9 codes for the diagnoses. For example, if your patient reports dry, itchy eyes and generalized pain, and you perform a complete exam to rule out other causes, and then decide to insert plugs in both eyes, you can code as follows:

Report the office visit (E/M code or eye exam code) with modifier -25 appended, linked to diagnosis code 379.91 (Pain in and around eye).

Report 68761 (Closure of the lacrimal punctum; by plug, each) on two lines and append -E2 (Lower left, eyelid) and -E4 (Lower right, eyelid), plus modifier -51 (Multiple procedures) to denote the lids, linked to diagnosis code 375.15 (Other disorders of lacrimal gland; tear film insufficiency, unspecified).

Most important: There is a 10-day global period for punctal plug insertions. If the patient reports improvement later, and returns within 10 days to have permanent plugs placed, you may only bill for the insertion - not a separate office visit - because the plug insertion is the only reason for that visit.
 
However, if the patient returns after 10 days, you can bill an E/M code just as before.