68761_R23

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

2.  Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The documentation must include the legible signature of the optometrist/ophthalmologist responsible for and providing the care to the patient.

3.  The submitted medical record must support the use of the selected ICD-10-CM code(s).  The submitted CPT/HCPCS code must describe the service performed.

4.  The medical record documentation must support the medical necessity of the services as directed in this policy.

5.  Patient’s records must contain evidence of:

• Patient’s complaints normally associated with dry eye syndrome
• Documentation of trial period of synthetic tears
• Decreased tear meniscus, punctate keratopathy, corneal ulcers, or erosions, an early tear break-up time, oily tear film, corneal filaments, corneal scars or nodules or an abnormal Schirmer’s test

Report closure of the lacrimal punctum; by plug, with CPT code 68761.

Closure of the lacrimal punctum is classified by Current Procedural Terminology as surgical procedure performed on the lacrimal system of the eye and ocular adnexa. 

This code describes a service that is performed per punctum and therefore must be submitted with an eyelid site modifier on the service line. 

The following site modifiers should be applied to CPT code 68761 as indicated:

• E1 – Upper left punctum
• E2 – Lower left punctum
• E3 – Upper right punctum
• E4 – Lower right punctum

For each service line, a unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.       

If multiple occlusion procedures are performed on the same day, then each additional occlusion procedure is coded on a separate service line with the modifier -51 (multiple procedure) attached to each service line.

2.  Sometimes punctal dilation is required to facilitate the insertion of the plug.  Therefore, CPT code 68801 – dilation of the lacrimal punctum with or without irrigation should not be billed as a separate procedure.  This carrier bundles that procedure code with closure of the lacrimal punctum; by plug with CPT code 68761.

Treatment Guidelines

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.

1.  Closure of the lacrimal punctum has a 10-day global period that begins the day after the surgery.  During this period of time, additional eye examinations or surgical procedures will not be paid unless there is an explanatory modifier attached to the eye examination code and/or the surgical procedure code.  In these cases, the -modifier -24 (unrelated E&M service by the same doctor during a postoperative period) would be applied to the service line with the eye examination and the modifier -79 (unrelated procedure/service by the doctor during the postoperative period) would be attached to the service line with the surgical procedure.

2.  No separate reimbursement is made for an eye examination on the same day as closure of the lacrimal punctum unless a separately identifiable service is provided and documented.  In this case, the modifier -25 (separate E&M srvice by the same doctor on the same day of the procedure or other service) would be applied to the service line with the eye examination.

3.  This Medicare carrier has no specific utilization guidelines for lacrimal punctal plugs; however these tests are reimbursed at a frequency based on medical necessity.

4.  In the absence of specific utilization guidelines, optometrists should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of optometric practice.