MAY 15, 2018
Billing Bilateral Punctal Plugs
Question: How should I bill punctal plugs with Medicare patients? We always bill the eye code with modifier -25, along with 68761 -RT and 68761 -LT, however Medicare is no longer processing the claim.
Answer: Even among Medicare Administrative Contractors there can be differences in billing. Verify with your MAC.
Most require bilateral punctal occlusion to be submitted as a single line item appended with modifier -50. Place 1 in the unit field and double your fee. CMS’ Medically Unlikely Edits published in April 2013 said that all bilateral procedures must be submitted this way. Payment will be 150 percent of the allowable.
Some MACs like Novitas also require the eyelid modifiers be appended after modifier -50.
Look at the exam documentation. While medically necessary, was the established patient exam performed solely to confirm the need to insert the punctal plugs? If yes, then the established patient exam is not separately billable as it does not meet the definition of modifier -25.
Learn more about minor procedures in Ophthalmic Coding: Learn to Code the Essentials.