Optometric Billing-Billing for an Exam on the Same Day as a Surgical Procedure Such as Dry Eyes or Epilation

It has always been my opinion that in order to bill for an exam on the same day as providing a surgical procedure, such as dry eyes, that one would have to have notated evidence that the examination portion of the encounter was not in fact related to the surgical procedure.  It turns out that after some further research into my coding guidelines this is not just my opinion, it is fact. Let's take a look at how this should be handled.

IE: The patient came into the office for a routine exam or yearly check-up and at that time it was decided that the patient qualified for punctal plugs or epilation. (The plugs would be rare in this instance as it is now necessary to try every other treatment possible BEFORE proceeding with inserting the plugs). 

So, in the example above, the physician would note that "the patient was in for a yearly check up and during the course of exam the patient described to the physician that though the drops he has been using for his dry eye syndrome help somewhat, they are still relatively ineffective at times and he would like to know if there is anything else he could try. At this time the physician offers the option of punctal plugs as they have been shown to be a very effective, though minimally invasive, method of treating the patient's condition. "

If  the condition above, or any other combination of supporting evidence, is present you now have a justifiable basis for billing the insurance company for 1) A comprehensive examination 2) Punctal Plugs. The example above would be billed in a manner similar to the following:

1) 92014-25 (25 modifier means the exam is a separate service from the actual plugs themselves)

2) 68761 (one plug in either eye) or 68761-50 (1 plug in both eyes) or 68761-51 (2 plugs in the same eye) or better still 68761 E1 (E1 meaning it was the upper left lacrimal duct E3 would be upper right and E2E4 are lower left and right respectively). SEE BELOW 

If the condition in the above example is not met, by no means should you bill an insurance company for an exam AND a surgical procedure.At this point, it is understood that the procedure for plugs or epilation etc. includes any examination that need be done. Furthermore,  UNLESS a patient comes into the office for an exam during the 10 DAYS subsequent to the punctal plug procedure for something UNRELATED to the previous procedure you cannot bill the patient's insurance for any further items. In this case, you would bill the proper examination procedure code, followed with a -24 modifier (unrelated E/M procedure during post-op period) SEE BELOW

CLICK HERE TO VIEW THE OFFICIAL MEDICARE COVERAGE INFORMATION FOR BILLING PUNCTAL PLUGS.

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