68761_R37

This Medicare carrier does not have a local coverage determination (LCD) for insertion of lacrimal punctum plugs.  The policy presented is to serve as a sample and is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.  

Documentation supporting the medical necessity of this item, such as ICD-10-CM codes, should be submitted with each claim.  Claims submitted without such evidence may be denied as being not medically necessary.  Medical records should be available upon request.

Medicare will consider lacrimal punctal plugs medically reasonable and necessary for patients with the following:

• Symptomatic, moderate, or severe dry eye syndrome when more conservative treatments (i.e., artificial tears) have proven to be ineffective; and
• A diagnosis of aqueous tear deficiency has been confirmed by:
• One or more of the following diagnostic tests: tear break-up time (TBUT), Schirmer test, ocular surface dye staining pattern (rose bengal, sodium fluorescein, or lissamine green); and
• Slit-lamp biomicroscopy exam.

CPT Code 68761 is used to represent the “closure of the lacrimal punctum; by plug, each”.  The word “each” refers to each plug that is placed in a punctum.  The punctum is an opening in the vertical lacrimal canaliculi, located on the upper and lower eyelid margin near the nose.

Since there are two puncta in each eye, if plugs are inserted in both puncta of one eye it is appropriate to bill 68761 twice on separate lines with the appropriate modifiers.  If both eyes are treated (all four puncta), then 68761 should be billed four times on separate lines with the appropriate modifiers.

The following modifiers should be applied to 68761 as indicated:

E1 – Upper left eyelid

E2 – Lower left eyelid

E3 – Upper right eyelid

E4 – Lower right eyelid

When more than one punctum is involved in the same session, the subsequent procedures are reimbursed at 50% of the allowed amount, consistent with Medicare’s multiple surgery rules.

CPT code 68761 does not differentiate between collagen and silicone plugs.  The same code is used for either type. Consequently, there may be both a diagnostic occlusion of the puncta and a therapeutic occlusion done on the same patient in a short time frame.  Modifier 76 (repeat procedure by same physician) should NOT be reported in this instance, because the two services, although coded the same, are performed for different purposes and are NOT repeat in nature.

Note:  While the choice of initially using collagen (temporary/dissolvable) or silicone (semi-permanent/non-dissolvable) is left to the clinician’s discretion, the semi-permanent plugs afford a more extensive trial of punctal closure, and may better serve to delineate candidates for permanent closure.

CPT code 68761 has a global period of 10 days (minor procedures with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period included in the fee schedule amount; evaluation and management (E&M) services on the day of the procedure and during this 10-day postoperative period are generally not payable).  After the 10th day following the insertion of lacrimal punctal plugs, visits related to insuring the integrity of the plugs may be billed as an E&M service.

Medicare does not allow separate payment for the following diagnostic tests: tear break-up time (TBUT), Schirmer test, ocular surface dye staining pattern (rose bengal, fluorescein, or lissamine green).  These tests are considered part of a general ophthalmological examination or E&M service.

Medicare does not allow separate payment for temporary punctual plugs (A4262-temporary, absorbable lacrimal duct implant, each) or silicone punctual plugs (A4263-permanent, long-term, nondissolvable lacrimal duct implant, each), as these are included in the procedure.  However, these HCPCS codes should be reported concurrently to the implant procedure as applicable.

In the event punctual dilation is required to facilitate plug insertion, the National Correct Coding Initiative (NCCI) edits developed by the Centers for Medicare & Medicaid Service (CMS) bundle this procedure (CPT code 68801 – dilation of lacrimal punctum with or without irrigation) with the insertion of punctual plugs.

TREATMENT GUIDELINE

1.  This Medicare carrier believes that Closure of the Lacrimal Punctum; by plug, is to be used for both diagnostic and treatment purposes.

This carrier refers to the initial occlusion procedure with collagen plugs as a diagnostic occlusion.  According to this Medicare carrier, if the patient has a type of dry eye that can be helped by punctal occlusion, the diagnostic occlusion will tell you that.

For example: Chronic dry eye symptoms include complaints of dryness, redness, burning, reflex tearing, itching and foreign body sensations.

If a patient experiencing any of these symptoms and has a diagnostic occlusion performed, and if the patient experiences relief from dry eye symptoms during the period of temporary occlusion, then this Medicare carrier believes that the positive response confirms the diagnosis of dry eye syndrome.

If a patient has a positive response to the diagnostic occlusion, then this Medicare carrier states that a therapeutic occlusion may be performed to treat the disease.

This therapeutic occlusion – also called permanent treatment – requires silicone or acrylic plugs to provide definitive therapy for dry eye syndrome.

Lacrimal punctum plugs are indicated in the treatment of chronic dry eye syndrome that has not responded to more conservative treatment of synthetic tears.  Symptoms of chronic dry eye syndrome include complaints of foreign body sensation, itching, excessive mucus secretion, dryness, burning, photosensitivity, redness, and pain.  The decision to use lacrimal punctum plugs should include at least one the following:

• Superficial punctate keratopathy
• Corneal erosions or ulceration
• Filamentary keratitis
• Corneal scarring
• Conjunctival findings, such as from the keratoconjunctivitis associated with Sjogren’s syndrome
• Dry eye symptoms (e.g., blurred vision, reflex tearing, mucous precipitation) not adequately relieved by artificial tears