Print | ShareCPT Code: 68801 Region: 24
Covered states: Kentucky, Ohio
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.
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
The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Medical record documentation should indicate that before these procedures were performed an adequate lacrimal work-up and non-invasive evaluation were completed. Such an evaluation should include at minimum:
- Consideration by history and physical examination (including slit lamp), of likely pre-punctal and/or non-obstructive causes for epiphora such as disturbances of ocular surface tear flow by lid malposition, allergy, dry eye, blepharitis; and
- Non-invasive testing to diagnose punctal or post-punctal obstruction and to identify the site and degree of obstruction, such as by using dye disappearance testing when appropriate; followed by
- Initiation of appropriate treatment.
The medical record must contain a clear procedure note documenting the anesthesia, dilation, probing and irrigation procedures and indicating the results, such as: the likely site(s) of obstruction and whether and to what degree patency has been confirmed /established, or persistent obstruction remains.
Report dilation of the lacrimal punctum with CPT code 68801.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim
- A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete
- The diagnosis code(s) must best describe the patient’s condition for which the service was performed
Dilation of the lacrimal punctum has a 10-day global period. An evaluation and management (E&M) code is not separately payable on the same day as these procedures unless a separately identifiable service is provided and documented in which case, it would be appropriate to attach modifier –25 to the E&M code.
CPT code 68801 is a unilateral code and must be submitted with a site modifier (LT, RT, or –50). Only one of these modifiers may be billed on a claim line. Bilateral services must be billed with a –50 modifier, rather than RT and LT modifier.
Dilation of the lacrimal punctum will be paid only once per eye regardless of the number of times the punctum is dilated.
No separate reimbursement is made for the dilation of nasolacrimal punctum when performed on the same day and same side as the probing procedures (CPT codes 68810-68815 or 68840). If these are billed together for the same side on the same date of service only CPT codes 68810, 68811, 68815 or 68840 will be paid.
Claims for Nasal Punctum/Nasolacrimal Duct Dilation and Probing with or without Irrigation services are payable under Medicare Part B in the following places of service:
- CPT code 68801 is payable in the following places of service: office, assisted living facility, inpatient hospital, outpatient hospital, emergency room, ambulatory surgical center, skilled nursing facility (Part A stay), nursing facility (not in a Part A stay), custodial care facility, independent clinic.
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