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Optometry Coding & Billing Alert

Reader Questions:

Look to Fee Schedule Database for Bilateral Guidance

Published on Sun Sep 19, 2004

Question: If I place punctal plugs in both of a patient's eyes, should I code it bilaterally? How will that affect reimbursement?

North Carolina Subscriber

Answer: You should definitely code 68761 (Closure of the lacrimal punctum; by plug, each) bilaterally. Append modifier -50 (Bilateral procedure) to 67861 to indicate that you placed plugs in both eyes.

Tip: To find out how reporting a CPT code bilaterally might affect your reimbursement, look at the Bilateral Surgery Indicator in column T of the Physician Fee Schedule Database. Here's what those numbers mean:
 

  •  0 - You cannot append modifier -50. The procedure is considered unilateral.
     
  •  1 - You can append modifier -50. The payer will pay you whichever is lower: the actual total charge for both sides, or 150 percent of the Fee Schedule amount for a single code.
     
  •  2 - You cannot append modifier -50. The procedure is inherently bilateral.
     
  •  3 - You can append modifier -50. The carrier will pay the lower of the actual charge for each side or 100 percent of the fee schedule amount for each side.
     
  •  9 - The bilateral concept does not apply.

    Code 68761 has 4.85 RVUs (for a fully implemented nonfacility) and a bilateral surgery indicator of "1." Therefore, reporting 68761-50 should yield 150 percent of the RVUs, or 7.275 RVUs. Multiply this by the conversion factor, 37.3374, to find your total reimbursement - $271.63.
     
    Note: These reimbursement figures represent Medicare's Physician Fee Schedule payment amount unadjusted for geographic region.

    - Answers to Reader Questions and You Be the Expert provided and/or reviewed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas.

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