CPT® 68761: Closure of the Lacrimal Punctum; By Plug, Each - JE Part B
CPT® 68761: Closure of the Lacrimal Punctum; By Plug, Each
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.
This is to update providers of the claim review findings for CPT® 68761 closure of the lacrimal punctum; by plug, each. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.
The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for CPT® 68761 closure of the lacrimal punctum; by plug, each. The quarterly edit effectiveness results from April 1, 2024, to June 30, 2024, are as follows:
Top Denial Reasons
- The documentation provided does not support the medical necessity for this number of services or items within this timeframe.
- Failure to Return Records
- The documentation submitted is not legible
Educational Resources
Education
The lacrimal system serves to keep the conjunctiva and cornea moist through the production, distribution, and elimination of tears. Tears produced by the lacrimal gland are drained from the eye through the lacrimal punctum, a small opening in the inner canthus. The physician administers a local anesthetic at the lacrimal punctum and closes the punctum by inserting a plug. The plug may be a permanent silicone plug or a temporary collagen plug. Documentation must support reason for continuing with temporary plugs versus using permanent plugs.
Failure To Return Records
The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Incomplete And/Or Insufficient Documentation
When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).
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