Dr. A.J. Contento on Punctal Occlusion: What to use, When to use it, and How to Bill

Dr. Contento Responds to Dr. Paul Karpecki’s Selected Targeted Treatments for Dry Eye

Punctal Occlusion: What to Use

To elaborate on Dr. Karpecki’s post, Selected Targeted Treatments for Dry Eye, I would like to discuss punctal occlusion using the ComforTear™ Punctum plugs. I currently use the Ocular Surface Disease Index, OSDI, questionnaire to help quantify normal, mild, moderate and severe dry eye symptoms. The history is taken and the determination is made to treat with OTC artificial tears like Systane®, Refresh Optive® or possibly thicker gels or ointments at bedtime.

I also use this as part on my pre-op PRK and Lasik verification of dry eye. Observations of the TBUT, tear film quality, volume analysis with quick zone, kerititis sicca staining with combination Fluorescein and Lissamine Green solution i.e., Fluramene™ or the individual strips of Lissamine green, are all recommended to assist in the diagnosis process.

Punctal Occlusion: When to Use It

I often treat using OTC products and document their success or failure. Patients prefer not having to instill multiple drops daily. Hence popping in pre-loaded ComforTear plugs is a quick and easy way for the practitioner to maintain the tear volume in the eye.

For long term punctal occlusion I use the ComforTear plug. It comes in four sizes:  .6, .7, .8, and .9mm; I use the .7mm “small” sized plugs most frequently because they go in easily and are comfortable for the patient. These also have Micro beams to provide strength. On occasion a patient will report feeling the plug, especially on eye movement. Often times this is the princess who feels the pea under 4 mattresses, so don’t feel badly.

For LASER pre-op cases I often consider plugs 10 days prior to the procedure to ensure that the surface is healthy for PRK or LASIK. These are also effective in allowing inserted drops to not drain out as quickly during the pre and post op periods. Dissolvable plugs are also used in the collagen and synthetic materials.

Punctal Occlusion: How to Bill

I was asked about how I bill for punctal plugs.  My billing manager, Raffaelina, uses the 68761 code with modifier e1, e2, e3,e4. This code is usually used as the E2 E4 lower punctum for the first occlusion and if we need to plug the uppers we use E1 E3.I didn’t make this up! We do not bill an office visit  92012 at the same time. We also know that the patient’s insurance can only be billed for this code and this covers the case for 10-14 days as a post-plug insertion ‘post op period’.

Use these diagnosis codes for best success, 370.33 375.15. We bill $350 on the first eye and $250 on the second eye and receive variable payments from different carriers.

I love to put the ComforTear plugs in my patients because the patient has usually not been given this option. They are frustrated with drops, they will be thrilled with outcome, they all rant and rave to their friends and family about how great the doctor is and how he/she went out of his/her way for them as a patient.

My wife, Dr. Annette Contento, was not a big fan of collagen plugs yet she is absolutely thrilled with the ease of the pre-loaded plugs. I sometimes use the economy packs when available and now use a magnifier, bio head set, or some magnification since my presbyopia has kicked in. At the University the interns and residents all practice on each other and they are often shocked at how easy it is to handle the inserter.

Overall I feel the dry eye patient who wears contacts is also helped with newer extended wearing times and more comfortable fits. Try plugs on that family or staff member and see the results for yourself. Let me know how it works out! You can do so by simply commenting below.