Coding & Reimbursement

Coding essentials for punctal plugs

Punctal occlusion is a common therapy for dry eye disease. Its usual treatment is punctal plug insertion. Let’s review the coding essentials.

Q. What are the indications for punctal occlusion with plug?

A. This procedure provides a therapeutic alternative when eyedrops and ointments have proven unsatisfactory. It is commonly performed for dry eye syndrome, keratitis sicca, punctate keratitis and keratoconjunctivitis. It might also be helpful treating a symptomatic patient following refractive or other anterior segment surgery.

Q. Is there just one type of punctal occlusion therapy?

A. No. Plugs come in different materials, including collagen and silicone, and can be placed in different areas, such as within the canaliculus.

Collagen plugs typically are absorbed within a couple of weeks. Some plugs are designed for extended duration, lasting three to six months, while others are intended to be permanent. Coding, billing, payment rates and charting are the same for all types.

Q. What documentation is required in the chart to support a claim?

A. Punctal occlusion with plugs is a surgical procedure. Therefore, the risks, benefits and alternatives need to be reviewed with the patient prior to the procedure, and the patient’s informed consent obtained. An appropriate operative report is needed. This includes any preparatory drops, which puncta were occluded, and a description of the brand, size and lot number of the plugs. Any postoperative instructions should also be noted. When a temporary or extended-duration plug is selected, be sure the medical record supports the medical necessity for that modality.

Medicare expects that a surgical procedure will not be performed as an initial treatment for dry eyes, so the chart should include documentation that other, less invasive therapies were unsuccessful or contraindicated. Other therapies would usually include artificial tears and, possibly, ointments.

Q. Does Medicare cover punctal occlusion with plug?

A. Yes, when medically necessary. Use 68761 (Closure of lacrimal punctum; by plug, each) to describe the professional service.

The 2018 Medicare Physician Fee Schedule allowable for in-office procedures is $152; it is reduced to $122 in a facility. These amounts are adjusted by local wage indices.

There is also a permitted facility fee, although the procedure is rarely performed in a facility. The 2018 ASC allowable for 68761 is $98, with the HOPD rate $268. No separate payment is made for the supply of the plugs in any venue.

Q. May we charge for an exam performed on the same day as the procedure?

A. Sometimes. Punctal occlusion by plug is considered a minor surgical procedure, with a 10-day global period. Minor surgical procedures include the visit on the day of surgery in the global surgery package, unless there is a separate and identifiable reason for the visit. When the visit is billable, modifier 25 is appended to the exam code; this indicates that the patient’s condition required an additional exam beyond the usual preoperative care provided for the procedure or service. Modifier 25 is not used to report an E/M service that resulted in a decision to perform surgery.

Q. How frequently do ophthalmology practices perform this procedure?

A. CMS utilization data for claims paid in 2016 show that 68761 was associated with about 2% of all office visits. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service twice.

Q. What codes do we use if we need to remove an implanted plug?

A. In rare cases, punctal occlusion may contribute to even greater patient discomfort and epiphora than were present prior to the procedure. Removal of most types of plugs, such as the “cap and anchor” style of silicone plug, is usually readily accomplished with forceps at the slit lamp. There would be no separate charge for this; it would be included with the exam on that date.

Dislodging an intracanalicular plug is easily accomplished by irrigating the lacrimal system with saline. Use CPT code 68801 (Dilation of lacrimal punctum, with or without irrigation) or 68840 (Probing of lacrimal canaliculi, with or without irrigation) to report this procedure, depending on the position and manipulation of the irrigating cannula.

Q. Will Medicare cover insertion of temporary plugs as a diagnostic test prior to permanent plugs?

A. Yes; Medicare will cover punctal occlusion by temporary plugs inserted as a diagnostic procedure (usually collagen), as well as permanent plugs (e.g., silicone, thermosensitive or hydrophilic), provided that both procedures are medically necessary. However, opinions differ regarding the merits of a trial using temporary punctal plugs, and the physician must decide in each case whether this is warranted. Be sure to document the medical necessity for inserting temporary plugs followed by permanent plugs.

When the physician decides to proceed with insertion of permanent plugs within the global period, this is considered a staged procedure. Modifier 58 is used on the claim for the permanent plugs to indicate that this is not a duplicate billing. Outside of the 10-day postoperative period, no special modifier is needed. Reimbursement is the same either way.

Q. If a plug “falls out,” may the replacement procedure also be billed?

A. Maybe. The physician may or may not charge based on the reason the plug was lost. A charge is likely if the patient didn’t follow postoperative instructions or if the plug was in place for a long time. A charge is not justified if the wrong plug size was used. Finally, if anatomical reasons are to blame for the plugs not staying in place, you are likely to use another method of punctal occlusion. OM