Ophthalmology and Optometry Coding Alert

Placing punctal plugs (implants which help to keep the cornea moist by blocking the punctum -- the entrance to the tear drainage system), requires careful coding in order to get reimbursed adequately for the procedure and the supply. We talked to two coders about the best ways to most adequately bill for the procedure and supplies.

There are two kinds of punctal plugs: permanent, which are made of silicone, and temporary, which are made of collagen. No one reimburses for the temporary punctal plugs, according to Tracy Copeland, insurance specialist with Thomas Larkin, MD and Associates, a two-ophthalmologist, two-optometrist practice in Denver, CO. The correct HCPCS code for the permanent version is A4263 (permanent, long-term, non-dissolvable lacrimal duct implant, each). The HCPCS code for the temporary (collagen) plug is A4262 (temporary, absorbable lacrimal duct implant, each) -- but dont expect to get paid.

It is essential that you use the correct HCPCS code, our sources note. If you file using A4262, and placed the silicone (permanent) plug, you will not be paid the $70 or so the plug costs you. And as will be seen below, sometimes the pay-up for the supply is better than the procedure reimbursement, so take the HCPCS codes seriously.

Both HCPCS and CPT Codes Important to Adequately Get Paid

Commercial carriers pay well for the supply, but not for the procedure, while Medicare pays well for the procedure, but not for the materials, Copeland says. So to have all your bases covered, make sure you are charging both supply and procedure codes properly.

First of all, always report the supply current to the implant procedure, which is 68761 (closure of the lacrimal punctum; by plug, each). The next question is whether to use the -50 modifier (bilateral procedure, at the same operative session), -RT (right eye) and -LT (left eye), or the E series (level II, HCPCS/National modifiers).

We do get paid for doing punctal plugs, but we dont get paid correctly all the time, says Copeland. The biller explains that every insurance company has its own system for reimbursing for this procedure (and the supply). Everybody pays all over the place, as she puts it. So you have to code the way they want you to.
Copeland uses the -50 modifier for both Medicare and commercial payers. If you do both eyes, our Medicare carrier likes the -50 modifier, she says. And in our geographic area, I think the -50 modifier works best for commercial payers too. Therefore, you would code the procedure 68761-50, and get paid twice -- to cover both eyes.

Angela Spurlin, insurance manager for Jacksonville Eye Clinic, a solo ophthalmologist in Jacksonville, NC, uses the E-series of modifiers to distinguish where the plugs [...]