As per research conducted in 2017, there are more than 16 million adults in the United States who are suffering from dry eye disease. This is just an estimate, and the real number is expected to be much higher than this. More patients mean more revenue for ophthalmology practices. However, this expected revenue is of no use if the practices can’t get reimbursement for their claims.
A common treatment for dry eye disease is punctal occlusion, which is billed via CPT code 68761. So, to benefit from the huge number of patients, you need to learn how to bill this code correctly.
In this guide, we have explained everything you need to know about 68761, from what it is, when you can use it, and most importantly, how to use it correctly. So, let’s start.
CPT Code 68761 – Description
CPT code 68761 is defined as:
“Closure of the lacrimal punctum; by plug, each.”
68761 is an ophthalmology code. It is used to bill a minor surgical procedure in which the physician performs punctal occlusion. Here’s what happens in the procedure.
During the surgery, the physician inserts a small plug into the tear ducts that are present on the eyelids. This is done to block tear drainage, so the eye can remain hydrated naturally.
Usually, this is required for dry eye patients, but it can be used to treat other ailments as well. An important point to note here is that under 68761, any type of plug can be used; a change of material does not affect the code. Also, the payment for the plug itself is bundled into the code; you cannot bill it separately.
Another point worth mentioning here is the word “each” in the definition. What it means is that 68761 is reported per punctum or tear duct, not per patient or per visit. Each eye has two ducts, so up to 4 plugs can be billed.
Scenarios Where CPT Code 68761 is Applicable
To make things clearer, let’s look at a couple of real-world scenarios in which CPT code 68761 can be used:
Scenario 1
Suppose a patient has chronic dry eye disease. He has been using over-the-counter artificial tears for several months, but there isn’t much relief. He goes to an ophthalmologist to get treatment. The physician takes a deep look at the eyes and performs some tests. The results show reduced tear break-up time along with punctate staining on the ocular surface.
Now, because conservative treatments have already failed and the dry eye diagnosis is confirmed, the physician opts for silicone plug insertion in the tear ducts.
The surgery is performed, and everything goes well. So, here, the billing department can use CPT code 68761 to bill each punctum treated.
Scenario 2
A patient recovering from LASIK surgery returns to the clinic reporting persistent burning, grittiness, and fluctuating vision several weeks after the procedure. Post-refractive dry eye is common, and the physician determines that temporary occlusion would support the ocular surface while the corneal nerves heal. A collagen plug is inserted into the lower punctum of the affected eye as a trial before considering a longer-lasting option.
The billing department bills CPT code 68761 with the corresponding eyelid modifier and a diagnosis code that reflects the post-surgical dry eye presentation.
Applicable Modifiers for CPT Code 68761
The following modifiers are frequently used with CPT code 68761:
| Modifier | Description | Application |
|---|---|---|
| E1 | Upper eyelid, left | Identifies punctal occlusion performed on the left upper eyelid. |
| E2 | Lower eyelid, left | Identifies punctal occlusion performed on the left lower eyelid. |
| E3 | Upper eyelid, right | Identifies punctal occlusion performed on the right upper eyelid. |
| E4 | Lower eyelid, right | Identifies punctal occlusion performed on the right lower eyelid. |
| RT / LT | Right or left side | Used by payers that do not recognize E-modifiers to indicate which eye was treated. |
| 50 | Bilateral procedure | Used by some payers to report bilateral occlusion instead of separate RT/LT lines. |
| 51 | Multiple procedures | Appended when more than one punctum is occluded in the same session. |
Note: Modifier acceptance varies by payer. Some carriers require the eyelid-specific E-modifiers, while others expect RT, LT, or 50. Confirm the preferred format with each payer before submitting.
CPT Code 68761 – Billing & Reimbursement Guidelines
Getting the code right is only part of the job. That’s why you should keep the following guidelines in mind before filing claims with CPT code 68761:
Reimbursement Division
We have already mentioned that 68761 is billed per punctum or tear duct. So, the number of units of code used must match the number of ducts treated.
Also, if multiple puncta are treated in the same session, then the first one is reimbursed at 100% of the original reimbursement amount, while the rest are reimbursed at 50% each.
Documentation Requirements
Payers expect the medical record to justify medical necessity before approving punctal occlusion. At minimum, documentation should include:
- The patient’s dry eye symptoms, their duration, and impact on daily activities such as reading or screen use.
- Evidence that conservative treatment, typically artificial tear supplementation, was attempted and failed.
- Objective testing results, such as Schirmer’s test, tear break-up time, or corneal staining, that confirm the diagnosis.
- Documented informed consent for the procedure.
- The specific punctum or puncta treated and the type of plug used.
Wrapping Up
Let’s end this guide here. CPT code 68761 is an important code for punctal occlusion. It is a common treatment for dry eye disease and a big source of revenue for healthcare providers. To bill it correctly, follow the guidelines that we provided in this blog.
However, medical billing isn’t everyone’s cup of tea. Many billers struggle with billing, especially highly specific ophthalmology codes. If your practice is running into denials or wants to offload the administrative burden entirely, MediBillMD’s ophthalmology billing services can help you file cleaner claims and recover the revenue you’re owed.
