Print | ShareCPT Code: 68801 Region: 37
States covered: General guidelines if your state does not have a local coverage determination
Title: Dilation of Lacrimal Punctum
Category
Minor Surgical Procedure
Description
Dilation of nasolacrimal punctum and probing of nasolacrimal duct, with or without irrigation are useful treatments when mechanical, inflammatory or infectious processes cause or contribute to obstruction of normal tear drainage resulting in epiphora (excess tearing) or persistent infection.
This Medicare carrier does not have a local coverage determination (LCD) for the dilation of the nasolacrimal punctum. 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.
Dilation of nasolacrimal punctum and probing of nasolacrimal duct, with or without irrigation are useful treatments when mechanical, inflammatory or infectious processes cause or contribute to obstruction of normal tear drainage resulting in epiphora (excess tearing) or persistent infection.
Dilation of the nasal lacrimal punctum is a useful treatment when mechanical, inflammatory, or infectious processes cause or contribute to obstruction of normal tear drainage resulting in excess tearing or persistent infection.
Dilation of the nasal lacrimal punctum may be medically necessary when obstruction at or distal to the lacrimal punctum is reasonably suspected to be causing or contributing to the patient’s symptoms, and when such measures are required to alleviate the patient’s symptoms and reduce the likelihood of infection or damage to the lacrimal drainage apparatus.
Dilation & Probing Procedures can be performed for any of the following conditions:
- Epiphora (excessive tearing) due to acquired obstruction within the nasolacrimal sac and duct
- Chronic dacryocystitis or conjunctivitis due to lacrimal sac obstruction
- A mucocele of the lacrimal sac
- Lacrimal sac infection that must be relieved before intra-ocular surger
The correct use of an ICD-10-CM code does not guarantee coverage of a service. The service must be medically necessary in the specific case and must meet the criteria specified in this Local Coverage Determination.
ICD-10 Diagnosis Codes
1. The medical record should clearly indicate the condition being evaluated; and the primary diagnosis should support the medical necessity of the procedure.
Before dilation and probing procedures are performed, pre-punctal disturbances of ocular surface tear flow such as eyelid malposition and non-obstructive causes such as ocular allergy, dry eye syndrome, or blepharitis should be excluded.
Tear volume measurements and tear film break-up time can indicate insufficiency or instability of the tear film which can cause or contribute to epiphora. Dye disappearance testing or Jones dye testing can be used to exclude significant obstruction of the nasolacrimal system and/or to help identify the site and degree of the obstruction.
2. Dilation of nasolacrimal punctum is considered for patients whose medical records indicate they have first undergone a thorough lacrimal apparatus evaluation that includes at least the following:
- Consideration by patient history and ocular examination, including biomicroscopy, of likely pre-punctal and/or non-obstructive causes for epiphora
- Non-invasive testing to diagnose punctual or post-punctal obstruction and to identify the site and degree of the nasolacrimal obstruction
3. The medical record should contain clear notes documenting the performance of the dilation, irrigation and/or probing procedures. If a bilateral procedure is performed, the medical record should support that both eyes had qualifying signs or symptoms and had undergone a proper pre-procedural lacrimal apparatus evaluation.
4. The medical record should indicate the results of the procedure such as the likely site(s) of obstruction and whether and to what degree patency has been confirmed and/or established, if a persistent nasolacrimal obstruction remains.
5. Documentation must be made available to Medicare upon request.
Report dilation of the lacrimal punctum with CPT code 68801.
- This code describes a service that is performed unilaterally and therefore should be submitted with a site modifier (-RT, -LT, or -50). Only one of these modifiers may be billed on a service line
- Eyelid modifiers do not apply. Even if both the upper and lower puncta of the eye are dilated, a unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.
- If this procedure is performed on both eyes, the -50 modifier must be applied to the service line. As before, a unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.
1. The Dilation & Probing Procedures have 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 -24 modifier would be applied to the service line with the eye examination and the -79 modifier 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 any of the Dilation & Probing Procedures unless a separately identifiable service is provided and documented. In this case, the -25 modifier would be applied to the service line with the eye examination.
3. Dilation and Probing & Procedures are contraindicated in the following clinical circumstances:
- Anatomical malformations in the lacrimal duct or bony lacrimal canal
- Recurrent episodes of active dacryocystitis
- Post-traumatic strictures with bony narrowing
- Tumor of the lacrimal sac