Optometry Coding & Billing Alert

Published on Tue Feb 22, 2005 PDF

One eye or both? Which eyelid? The answers affect how you bill

Two eyes, four eyelids - keeping track of how to report multiple plug insertions with the proper modifiers can be daunting. Below are some examples, with the CPT codes and the units, of how to bill for specific procedures.

Note: Many payers, including most Medicare carriers, do not require you to append modifier -51 (Multiple procedures); their claims processing software will automatically add that modifier to any item listed after the first line.

Example 1: One silicone plug in lower left eyelid

Line 1: 68761-E2 (1 unit)

Line 2: A4263 (1 unit)*

Example 2: One silicone plug in lower left eyelid, one silicone plug in lower right eyelid

Line 1: 68761-E2 (1 unit)

Line 2: 68761-51-E4 (1 unit)

Line 3: A4263 (2 units)*

Example 3: One silicone plug in upper left eyelid, one silicone plug in lower left eyelid, one silicone plug in lower right eyelid

Line 1: 68761-E1 (1 unit)

Line 2: 68761-51-E2 (1 unit)

Line 3: 68761-51-E4 (1 unit)

Line 4: A4263 (3 units)*

Example 4: One silicone plug in each eyelid

Line 1: 68761-E1 (1 unit)

Line 2: 68761-51-E2 (1 unit)

Line 3: 68761-51-E3 (1 unit)

Line 4: 68761-51-E4 (1 unit)

Line 5: A4263 (4 units)*

*Note: Medicare and some private carriers bundle payment for A4263 (Permanent, long-term, nondissolvable lacrimal duct implant, each) into the fee for 68761 (Closure of the lacrimal punctum; by plug, each). When submitting to those carriers, omit this line from your claim.