Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 25, 2006 PDF

Report 68761 using E1-E4

When it comes to punctum plugs or punctum closures, keep your eyes on the prize by showing the procedures are medically necessary. Here's how.

Most Medicare carriers want you to report code 68761 (Closure of the lacrimal punctum; by plug, each) once per eyelid, using E1-E4, says Kristen Keller, billing manager at Five Points Eye Care in Athens, GA. But if you insert more than two plugs, be prepared to justify the medical necessity.

Medicare feels that "[i]n most cases of dry-eye syndrome requiring punctum plugs or punctum closure, placement of one plug in (or closure of) each lower punctum will suffice to alleviate the problem," states TrailBlazer's local coverage determination for 68761. "Medicare will reimburse for two plugs per beneficiary or two permanent closures per beneficiary on any given day. Up to two additional plugs or two additional closures may be performed for a total of four, but documentation must clearly show that the two additional plugs or closures were medically necessary as additional treatment to alleviate the condition."

Example: A Medicare patient presents with severe dry-eye syndrome. The optometrist places silicone plugs in each eyelid and has documentation showing that all four plugs were medically necessary.

Report the service as follows:

• Line 1: 68761-E1 (1 unit)
• Line 2: 68761-E2 (1 unit)
• Line 3: 68761-E3 (1 unit)
• Line 4: 68761-E4 (1 unit)

Note: Medicare reimbursement for 68761 includes payment for the plugs themselves. Caution: Do not code separately for the supplies with HCPCS codes A4262 (Temporary, absorbable lacrimal duct implant, each) or A4263 (Permanent, long-term, nondissovable lacrimal duct implant, each).