Coders are often confused about when to use the eyelid modifiers: -E1 for upper left, -E2 for lower left, -E3 for upper right, and -E4 for lower right. Three common ophthalmological procedures require the eyelid modifiers: epilation (67820-67835), punctal plug procedures (68761-68815), and chalazion excisions (67800-67805). In addition, 67810* (Biopsy of eyelid), 67840* (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure) and 67850* (Destruction of lesion of lid margin [up to 1 cm]) may be performed on different lids.
Use the E modifiers when a procedure can be performed on any one of the four eyelids. If the definition of a procedure code specifies that it is only performed on the lower eyelids (e.g., 15820 [Blepharoplasty, lower eyelid]), use modifier -50 (Bilateral procedure) to indicate that both lower eyelids were operated on.
Epilation Rules Vary
Carriers have varying requirements for epilation. If your carrier pays by the eye as CPT dictates code with the body-side modifiers. If your carrier pays by the lid, use the lid modifiers.
For example, if your carrier has a local medical review policy (LMRP) that allows billing by the eye and you remove a lash on each eye, code epilation of a lash on either the upper or lower left lid (67820-LT), and code a lash on either the upper or lower right lid (67820-RT). If your carrier pays by the lid and you remove a lash on the upper left and lower right lids, report 67820-E1 and 67820-E4.
Few carriers have an LMRP that allows billing for each lash epilated. If you're in such a state, local modifiers must be used, such as -Y2 for the first lash, -Y3 for the second, and so on up to -Y9 for the eighth, then -Z2 for the ninth, -Z3 for the 10th and -99-U2 for the 11th and any additional lashes.
Charge for Punctal Plug Supply
CPT Code 68761 (Closure of the lacrimal punctum; by plug, each) is used per lid. However, Medicare does not reimburse the supply code for this procedure (A4263, Permanent, long-term, nondissolvable lacrimal duct implant, each). Nonetheless, you may still bill private payers for punctal plugs unless your LMRP states otherwise. Report A4263 or 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) for each plug inserted, using the units field in your billing system. Because 99070 is nonspecific, you should include the invoice for the supplies or materials. Ophthalmologists can even bill for temporary plugs (A4262, Temporary, absorbable lacrimal duct implant, each) by invoice to private payers.
Temporary plugs last four to six weeks in the average patient, [...]