Code Punctal Occlusion Procedures With Precision
Pay attention to eyelid locations for correct E modifier usage. For millions of people across the United States, dry eyes quickly turn a good day into a day of suffering, with itching, tearing, feelings of grit or foreign body, or general eye ache. Dry eye syndrome (DES) occurs when the eye doesn’t adequately produce natural tears, or the tears that are produced dissipate quickly, leaving the surface of the eye without a natural protective barrier. This tear insufficiency can cause ocular surface inflammation, damage, and discomfort. An eyedrop regimen is the first and most typical treatment for DES with either over-the-counter or prescription drops. However, this regimen often does not adequately manage symptoms. Closure or blockage of the puncta, which are the openings at the nasal edges of the upper and lower eyelids where tears naturally drain, allows the eye to retain more natural tears by slowing or preventing over-drainage. Read on to learn how to code punctal occlusion procedures for your optometry and ophthalmology practices. What Are the Options for Punctal Occlusion? The most common closure occurs when a tiny device known as a punctal plug is inserted in the punctum to act as a stopper to slow or prevent tears from draining. Code 68761 (Closure of the lacrimal punctum; by plug, each) represents placement and positioning of the plug. Plugs can be collagen, which dissolve over time, or silicone, which are meant to be permanent. The CPT® code for insertion includes both temporary and permanent plugs, as the procedure to place them remains the same. Medicare includes the supply of the plug with the reimbursement for the procedure. Payers who follow Medicare rules also will not reimburse separately. Very few payers reimburse separately for the material supply, so you should check with your payer for details if you are unsure. For payers who will reimburse for the plug supply, use A4262 (Temporary, absorbable lacrimal duct implant, each) for a collagen plug and A4263 (Permanent, long term, non-dissolvable lacrimal duct implant, each) for a silicone plug. Less common, but no less effective, is closure of the puncta by permanent or semi-permanent measures. Assign code 68760 (Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery) when any of the following measures are employed: Understand How to Bill the Procedures While the procedures themselves seem simple enough, many nuances exist when it comes to coding for correct punctal occlusion reimbursement. Both 68760 and 68761: Modifiers add details: Append modifier 50 (Bilateral procedure) to indicate a bilateral procedure. Modifiers RT (Right side) and LT (Left side) identify the specific laterality where the procedure occurred. E modifiers indicate the specific punctum by location: upper or lower, and which side of the body. Be careful, however; while most laterality moves right to left, E modifiers for eyelids move left to right: Diagnosis coding: Frequent diagnosis codes include the following, but are not limited to these conditions: Important: Always bill a bilateral ICD-10-CM code where one exists, instead of two diagnosis codes for right and left. For example, H16.143 (Punctate keratitis, bilateral). Put It All Together For single closure, bill 68760 or 68761, apply the appropriate laterality or E modifier to indicate the closed punctum, and use the appropriate character to identify laterality with the ICD-10-CM codes. As a general rule, Medicare prefers modifier 50 for a bilateral closure. Bill on one line with a unit of 1, double the fee, and append the bilateral diagnosis. Medicare Advantage plans, commercial payers, and Medicaid coverages may follow Medicare guidelines or may have unique rules. Some possibilities include: When all four puncta are closed, billing can be trickier. Modifier 50 may not seem appropriate as it defines only two closures, one on each side. The most accurate representation would be four lines with E modifiers. However, be aware of the unusual circumstance where a payer prefers two lines and/or modifier 50, such as 68761-50-E1-E3 followed by 68761-50-E2-E4 — it happens! Lastly, ensure the procedure note is clear to show placement of four individual plugs. If a chart note request comes from the payer, documentation should support the coding to avoid denials or takebacks. Know How Often the Patient Can Receive Services Code 68760 does not have a lifetime limit or frequency limitation; however, as a more permanent closure, you would not anticipate billing this procedure on a regular basis. For example, sutures may not be permanent, but it would not be expected to suture the puncta every three months. Code 68761 also does not have a frequency limitation. Collagen plugs commonly dissolve in roughly three months or 12 weeks, so submitting up to four claims per year is not unreasonable. Medicare reimburses for 68761 when a plug or plugs are inserted on a quarterly schedule. Verify with other payers if a frequency limitation exists. Ultimately, punctal occlusion brings relief to many patients suffering from symptoms and side effects of DES. The need for eyedrops may never be eliminated, but patients may retain more of their natural tears, allowing them to forego the drops just a little longer. Christine Killeen CPC, CPB, CPMA, COPC, Contributing Writer
