Coding

Documenting punctal plugs

Does your patient have specific coverage guidance you must follow?

PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

Your doctor sees an established patient with severe dry eye who has not been on artificial tear products of any kind. Your practice documents this in the patient’s chart, and the doctor recommends both frequent use of artificial tears and punctal plugs in both lower lids.

Is this enough to support your claim for the plugs? The answer is “maybe” — your patient’s insurance might not think so if they have written specific guidance. Note: If you ask about the exam on the same day as a minor procedure, that was discussed in a previous OP article on modifier 25 (See tinyurl.com/OPCodingJuly15).

Will they pay?

Some payers are happy to pay for punctal plugs as long as the chart shows dry eye, while others are more restrictive — they want you to have exhausted or tried other less expensive options first. Palmetto GBA, the Medicare Administrative Contractor (MAC) for some states, has a specific policy that covers this and makes a few other demands on providers to justify the medical necessity in their opinion. First Coast Service Options (FCSO), in their Local Coverage Determination #L36232 on Diagnostic Evaluation and Medical Management of Moderate-Severe Dry Eye Disease, notes the following under management of dry eye:

Treatments for dry eyes aim to restore or maintain the normal quantity and quality of tears in the eye to minimize dryness … Tear replacement is frequently unsuccessful when used as the sole treatment if additional causative factors are not concomitantly addressed. Specific treatment recommendations depend on severity and cause. The sequence and combination of therapies should be determined on the basis of the patient’s needs and the treating ophthalmologist’s or optometrist’s medical judgment.

The American Academy of Ophthalmology (AAO) recommends the following conservative interventions … :

• Elimination of exacerbating medications where feasible

• Ocular environmental interventions (computer work site interventions, household allergens exposure)

• Aqueous tear enhancement with topical agents or external means

• Treatment of contributing ocular factors (e.g. blepharitis or meibomianitis)

• Correction of identified lid abnormality

• Medications (anti-inflammatory agents [e.g. topical cyclosporine and corticosteroids] and systemic omega-3 fatty acids)

They go on to state:

When medical therapy is not effective or contraindicated, punctal occlusion may be accomplished by inserting lacrimal punctal plugs … to decrease tear clearance and increase retention of the tear film by blocking the outflow of tears to the nasolacrimal system … Punctal occlusion and/or tarsorrhaphy (to reduce the evaporative surface area of the ocular surface) are indicated in cases of DED that are refractory to conservative management.

Under Indications, FCSO notes:

Lacrimal punctal plugs are considered medically reasonable and necessary for patients with the following:

• Symptomatic moderate or severe dry eyes that are not adequately treated by conservative interventions including a two or more week trial of artificial tears, ophthalmic cyclosporine where indicated, and adjustment to medications that may contribute to dry eye syndrome; and

• A diagnosis of aqueous tear deficiency confirmed by one or more of the following diagnostic tests: tear break-up time (TBUT), Schirmer test, ocular surface dye staining pattern (Rose Bengal, fluorescein, or lissamine green); and slit-lamp biomicroscopic exam.

Lastly, they state:

Punctal occlusion procedures are considered not medically reasonable and necessary for the treatment of contact lens intolerance.

If FCSO was the payer in the example above, your practice did not provide enough documentation for the payer. The use of plugs is much better supported if the history showed that tears (both preserved and non-preserved) and other drugs were tried and failed to provide relief, and that the proper testing and exam notes were present. It would not be necessary for the doctor to have the patient “fail treatment” again merely to get proper treatment. Any testing the doctor does is likely OK, and there would be no issues for an auditor to point to as problematic.

Also, remember that punctal plugs (CPT 68761) are a unilateral procedure code — each eye needs to be supported.

Conclusion

Some payers have specific guidance that you must follow — even for something as seemingly straightforward as the need for inserting punctal plugs. Documentation of the reason(s) your providers choose this treatment option and what they tried in the past is key to support your claims. OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.