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.
#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.
