DEC 18, 2019
Billing Punctal Plugs for Medicare
Question: How should I bill punctal plugs for Medicare patients? We always bill the Eye visit 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 (MAC) 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 (MUEs) published in April 2013 said that all bilateral procedures must be submitted this way. Payment will be 150% of the allowable. Some MACs like Novitas also require the eyelid modifiers be appended after modifier -50.
Regarding how to bill an exam the same day as this minor surgical procedure, look at the exam documentation. Although medically necessary, if the established patient exam is performed solely to confirm the need to insert the punctal plugs, then the established patient exam is not separately billable because it does not meet the definition of modifier -25.
Learn more about minor procedures in Ophthalmic Coding: Learn to Code the Essentials.