We developed this guide to provide you with basic information for obtaining reimbursement for punctal occlusion. The reader is strongly encouraged to review official instructions from the Centers for Medicare and Medicaid Services (CMS) and local Medicare carriers and to be familiar with the rules and definitions published in Current Procedural Terminology (CPT® the American Medical Association). In addition, check with local insurance carriers for approved diagnosis codes and any payer-specific usage guidelines for these services.
To assist you with filing, we provide Op-Notes™ peel-and-stick documentation labels with each punctal occluder (see example). It is important that you use these labels in your chart, as they contain the plug type, size and lot number, along with other required information for traceability.
Note the patient's symptoms (i.e., itching, burning, redness, tearing) as well as related illnesses such as Sjögrens disease or rheumatoid arthritis. Identify any inhibitions to regular activities of daily living that result from the patient's condition. Describe the patient's prior experience with artificial tears or other therapies for dry eyes. List current medications, particularly any with ocular side effects.
Document evaluation of tear production (using TBUT, Lissamine Green, Zone Quick™, Schirmer Test or observation of tear meniscus, etc.) and patient's corneal condition.
Discuss and document risks and benefits of punctal occlusion as well as alternative therapeutic options.
Many third-party payers consider occlusion of punctum by plug, 68761, to have a ten day post-op global period following the insertion of temporary or permanent plugs. As a result of these restrictions and of common clinical protocol, providers usually wait ten days after the insertion of temporary plugs, before assessing the benefit of the plugs and then inserting permanent plugs.
Diagnosis & Procedure Codes
Diagnosis Codes (ICD-9)
375.15 - Tear film insufficiency
NOTE: Supplemental diagnoses may apply, such as:
365.11 - Primary open angle glaucoma
370.20 - Superficial keratitis
370.33 - Keratoconjunctivitis sicca
710.2 - K. sicca associated with Sjögren's disease
714.0 - Rheumatoid arthritis
CPT Procedure Codes
68761 - Closure of the lacrimal punctum; by plug, each
25 - Separately identifiable E/M service on the day of a procedure
51 - Multiple procedures
Punctum Specific Codes
E1 - Left upper lid
E2 - Left lower lid
E3 - Right upper lid
E4 - Right lower lid
The information above is compiled from various sources and is subject to change without notice. It is intended as a guide only. Allowable and payable amounts may vary. We cannot guarantee the accuracy of any information contained herein. MPR-011 Rev. 04 (May 2008)