LCD/NCD Portal

L29210

 

LACRIMAL PUNCTAL PLUGS

 

06/14/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

 

FCSO Medicare will consider lacrimal punctal plugs medically reasonable and necessary for patients with the following:

• Symptomatic, moderate, or severe dry eye syndrome when more conservative treatments (i.e., artificial tears) have proven to be ineffective;

And

• A diagnosis of aqueous tear deficiency has been confirmed by:

o One or more of the following diagnostic tests: tear break-up time (TBUT), Schirmer test, ocular surface dye staining pattern (rose bengal, sodium fluorescein, or lissamine green);

And

o Slit-lamp biomicroscopy exam.

• The CMS On-line Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 13.5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel."

o Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

o A qualified physician for this service/procedure is defined as follows:

 A) Physician is properly enrolled in Medicare.

 B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

 

CPT/HCPCS Codes

 

 

68761 CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH

 

 

ICD-9 Codes that Support Medical Necessity

 

 

370.33 KERATOCONJUNCTIVITIS SICCA NOT SPECIFIED AS SJOGREN'S

375.15 TEAR FILM INSUFFICIENCY UNSPECIFIED

 

 

Documentation Requirements

• Medical record documentation must include the following:

o Patient’s complaints normally associated with dry eye syndrome (e.g., dryness, redness, burning, reflex tearing, itching, foreign body sensation, grittiness, stinging, soreness, photophobia and pain).

o Results of physical examination, including external examination and slit-lamp biomicroscopy exam.

o Results of one or more of the following diagnostic tests: tear break-up time test (TBUT), Schirmer test, ocular surface dye staining pattern (rose bengal, fluorescein, or lissamine green).

o Evidence of trial period of artificial tears that proved unsuccessful in relieving the patient’s symptoms, preceding the decision to place the lacrimal punctal plugs.

o Operative report to include the type of plug used and which puncta were involved.

• Documentation on follow-up visits after placement of the collagen or silicone plugs must indicate the status of the patient’s symptoms.

• All coverage criteria must be clearly documented in the patient’s medical record and made available to Medicare upon request.

 

Utilization Guidelines

• Generally, repetitive use of temporary lacrimal punctal plugs for treatment of dry eye syndrome would not be expected.

Treatment Logic

• Dry eye is a disorder of the tear film due to tear deficiency or excessive tear evaporation and involves damage to the ocular surface, which may result in an epithelial disorder called keratoconjunctivitis sicca (KCS), dry eye syndrome (DES) or dysfunctional tear syndrome (DTS) and is associated with symptoms which include: dryness, redness, burning, reflex tearing, itching, foreign body sensation, grittiness, stinging, soreness, photophobia and pain. In moderate cases, the ocular discomfort becomes marked and visual acuity may be reduced.

o Diabetic patients and patients with other corneal neuropathies may exhibit signs of DES with or without discomfort.

• To determine the appropriate treatment, an eye examination should be performed to exclude other causes of irritation of the ocular surface.

• These may include eyelid malposition, inturned eyelashes, incomplete lid closure, allergies, meibomian gland disease, ocular inflammatory processes or systemic diseases (i.e., rheumatoid arthritis, diabetes). Corneal sensation should also be assessed when trigeminal nerve dysfunction is suspected.

• When medical therapy is not effective, punctual occlusion may be accomplished by inserting lacrimal punctal plugs into the punctal orifice to decrease tear clearance and increase retention of the tear film by blocking the outflow of tears to the nasolacrimal system.

• The occlusion of lacrimal puncta by collagen plugs (temporary/dissolvable) is generally used for the diagnosis of dry eye syndrome.

o The collagen plugs dissolve within one to two weeks. If a trial of temporary punctual occlusion proves successful, semi-permanent/non-dissolvable occlusion is usually considered.

• Silicone or thermal labile polymer plugs (semi-permanent/non-dissolvable) are therapeutic and are generally used after the diagnosis has been made.

o After the silicone plugs are inserted, the patient intermittently returns to the physician to insure the integrity of the plugs.

• While the choice of initially using collagen (temporary/dissolvable) or silicone (semi-permanent/non-dissolvable) is left to the clinician’s discretion, the semi-permanent plugs afford a more extensive trial of punctal closure, and may better serve to delineate candidates for permanent closure.

 

Sources of Information and Basis for Decision

 

Altan-Yaycioglu, R., Gencoglu, E., Akova, Y., Dursun, D., Cengiz, F., & Akman, A. (2005). Silicone verus collagen plugs for treating dry eye: results of a prospective randomized trial including lacrimal scintigraphy. American Journal of Ophthalmology. Retrieved March 30, 2007 from mdconsult database (68579271).

 

American Academy of Ophthalmology. (2003). Preferred Practice Patterns for Dry Eye Syndrome. Retrieved March 30, 2007 from www.aao.org website.

 

Clinician SynerMed Communications. (2006). State-of-the-art management of chronic dry eye: a growing public health concern, 24(16), 1-18.

 

Corcoran, K. (2005). Find the proper documentation requirements and reimbursement potential for diagnosing and treating dry eye syndrome. Optometric Management. Retrieved on April 5, 2007 from www.optometric.com (71542).

 

CPT Assistant, June 1996, p.11.

 

Optometric Clinical Practice Guideline. (2002). Care of the Patient with Ocular Surface Disorders. Retrieved March 30, 2007 from www.aoa.org website.

 

Yanoff. (2007). Ophthalmology (2nd ed.). Retrieved March 30, 2007 from mdconsult database (68579271).

 

06/14/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29210 Lacrimal Punctal Plugs