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Medicare Reimbursement for Punctal Occlusion with Plug

Topic: Punctum Plugs

Sponsor: Corcoran Consulting Group

Updated: 02/21/2022

Corcoran Consulting Group

This procedure provides a therapeutic alternative when eye drops and ointments have proven unsatisfactory. It is commonly performed for dry eye syndrome, keratitis sicca, punctate keratitis, and keratoconjunctivitis. It may also be helpful treating a symptomatic patient following refractive or other anterior segment surgery.

Medicare does not expect that a surgical procedure will be performed as an initial treatment for dry eyes. The chart should include documentation that other, less invasive, therapies were unsuccessful or contraindicated. At the very least, other therapies usually include artificial tears, and may include ointments.

This FAQ addresses the following:

  1. Does Medicare cover punctal occlusion with plug?
  2. What are the indications for punctal occlusion with plug?
  3. What documentation is required in the medical chart to support this service?
  4. May we charge for an exam on the same day as the procedure?
  5. How do we indicate on the claim form which puncta were treated?
  6. If a plug “falls out”, may the replacement procedure also be billed?
  7. How frequently is this procedure performed?
  8. What is the Medicare reimbursement for punctal occlusion with plug?
  9. Is there a facility fee if the procedure is performed in an ASC or an HOPD?
  10. Will Medicare cover insertion of temporary plugs as a diagnostic test prior to permanent plugs?