Does your ophthalmology practice bill for punctum plugs? Below are six tips to get your claims paid timely.

#1 Documentation requirements prior to punctal plugs include: 1) patient’s unique complaint (not cloned), chart documentation should describe the patient complaint as dry, burning, itching and/or excessive tearing, 2) what methods for relief have been tried and failed, 3) evidence of tear deficiency, Schirmers tear test, Lissamine green, tear film break-up time or usage of Lissamine green with osmolarity.

#2 CPT 68761 has a MUE edit of 4. You may bill up to 4 units per session.⁣PUNCTAL PLUGS

⁣#3 Billing for a bilateral procedure? Use modifier -50, 1 unit, and double the price. When performing multiple or bilateral procedures, the first procedure is paid at the full allowable, and the second and subsequent procedures are reduced to 50% of the allowed amount. Check out the Novitas Modifier 50 Fact Sheet for more information.

#4 When punctal plugs are placed in all four punctae, use 68761-E1, 68761-E2, 68761-E3, 68761-E4. ⁣ ⁣

#5 Medicare bundled the supply of the plugs with the proceudure in 2002. Non-Medicare payers may pay separately for the supply of the plug with HCPCS codes: A4262 for collagen and A4263 for silicone.⁣

#6 Billing for an exam with plugs on the same day? Make sure the criteria for using the -25 modifier is met. Otherwise, the payer will consider the exam inclusive in the plugs payment.

Coding and billing have you stumped? The Eye Med Management team stays up to date on coding changes and best practices. Learn how our team can help you avoid costly errors and see increased revenue by contacting us today.

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