CPT 68761: Billing & Coding for Punctal Occlusion

Punctal occlusion is one of the few early-stage dry eye treatments that is directly reimbursable by Medicare and most third-party insurers. For practices that manage dry eye disease, understanding how to bill correctly for CPT 68761—and how to maximize reimbursement across multiple puncta—is essential to building a financially sustainable specialty dry eye practice.

This guide covers everything you need to submit clean claims for punctal occlusion: the procedure code, applicable modifiers, supported diagnosis codes, and documentation requirements.

What Does CPT 68761 Cover?

CPT 68761—Closure of the lacrimal punctum by plug, each—is the procedure code used for all punctal plug insertions, regardless of plug type. Collagen diagnostic plugs, synthetic absorbable plugs, and permanent silicone plugs are all billed under the same code. Reimbursement does not vary by material.

The code is billed per punctum. When more than one punctum is occluded during the same visit, the first procedure is reimbursed at 100% of the allowed fee; each additional punctum is reimbursed at 50%. Four-puncta occlusion generates significantly higher reimbursement than a standard general eye exam. Medicare rates are updated annually; check the current Medicare Physician Fee Schedule for your locality to confirm allowed amounts.

Supply Codes

In addition to CPT 68761, a supply code may be applicable depending on the payer. Medicare bundles the supply of collagen or silicone plugs into the procedure fee—plugs are not billed separately under Medicare. Some private insurance carriers, however, may accept a separate supply code:

A4263 (HCPCS) — Lens, intraocular, inserted in anterior or posterior chamber of eye
99070 — Supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered

Check with each patient’s carrier before submitting a supply code separately to avoid denials.

Reimbursement Rates

Medicare reimbursement for CPT 68761 is determined by the Medicare Physician Fee Schedule (MPFS) and varies by geographic locality. Rates are updated annually each January. To confirm current allowed amounts for your practice location, use the CMS Physician Fee Schedule Look-Up Tool.

Private payer rates vary by contract and are not subject to the MPFS. Verifying benefits and pre-authorizing the procedure with the patient’s carrier before the visit reduces the risk of denials and patient billing disputes.

Modifiers & Punctum Identification

Because CPT 68761 is billed per punctum, accurate use of laterality modifiers and punctum-specific identifiers is critical to clean claim submission. Errors in modifier usage are among the most common sources of punctal occlusion claim denials.

Punctum Identifiers

When billing for more than one punctum, each must be identified individually using the following codes:

E1 — Upper lid, left
E2 — Lower lid, left
E3 — Upper lid, right
E4 — Lower lid, right

These identifiers should be appended to CPT 68761 for each individual punctum billed on the same date of service.

Laterality Modifiers

In addition to punctum identifiers, laterality modifiers may be used depending on the payer:

-RT — Right side
-LT — Left side
-50 — Bilateral procedure

Not all payers recognize the same laterality modifiers. Some payers prefer E-codes; others accept -RT/-LT; others require -50 for bilateral procedures. Confirm modifier requirements with each carrier before submitting.

Additional Modifiers

-25 — Separately identifiable evaluation and management service by the same physician on the same day. Use when an E&M service is provided on the same day as punctal plug insertion and the E&M is significant and separately documentable from the procedure itself.
-51 — Multiple procedures. Used when more than one procedure is performed at the same session. Note that the multiple surgery rules apply to CPT 68761: the first punctum is reimbursed at 100%, and each additional punctum on the same date of service is reimbursed at 50%.

Important Billing Rules

CPT 68761 includes the office visit. Do not bill simultaneously for the encounter using a 920XX or 992XX E&M code on the same date of service for the same condition, unless modifier -25 applies and the E&M service is separately documented and identifiable.
The post-operative period for CPT 68761 is 10 days. Office visits submitted during this window for the same condition will not be separately reimbursed.
Allow at least 10 days following collagen plug insertion before inserting permanent plugs and billing an additional CPT 68761. Submitting within the post-operative period of the initial procedure will result in denial.

ICD-10 Diagnosis Codes for Punctal Occlusion

A valid ICD-10 diagnosis code is required on every CPT 68761 claim. Use the most specific code that accurately reflects the patient’s documented condition. Selecting a code that does not support medical necessity for punctal occlusion is a common cause of denial.

Primary Diagnosis Codes

The H04.12x series is the most direct diagnostic support for punctal occlusion:

H04.121 — Dry Eye Syndrome of Right Lacrimal Gland
H04.122 — Dry Eye Syndrome of Left Lacrimal Gland
H04.123 — Dry Eye Syndrome of Bilateral Lacrimal Glands

Secondary Diagnosis Codes

The following codes may support a CPT 68761 claim as primary or secondary diagnoses depending on the patient’s presentation:

H16.109 — Unspecified superficial keratitis, unspecified eye
H16.229 — Keratoconjunctivitis sicca, not specified as Sjögren’s
H57.8 — Other specified disorders of eye and adnexa (redness or discharge)
M35.01 — Keratoconjunctivitis sicca associated with Sjögren’s disease

Diagnosis Code Selection

When a patient presents with both dry eye and an underlying systemic condition such as Sjögren syndrome or rheumatoid arthritis, code the systemic condition as a secondary diagnosis alongside the primary dry eye code. This supports medical necessity and provides a more complete clinical picture for the payer.

If the patient’s dry eye is a consequence of refractive or cataract surgery, document this clearly in the medical record. Post-surgical dry eye is a clinically and documentarily distinct presentation from idiopathic DED, and the record should reflect that distinction.

Documentation Requirements

Proper documentation is as important as proper coding. Incomplete or insufficiently specific documentation is the most common reason a technically correct claim is denied on medical necessity grounds. The medical record should support the clinical rationale for punctal occlusion at the time of service.

Required Documentation Elements

At minimum, the medical record should include:

The patient’s dry eye complaint and history. Document the patient’s pertinent symptoms, their duration, and their impact on daily activities including work, reading, and screen use.
Evidence of failed conservative treatment. Document prior use of artificial tear supplements and the patient’s continued symptoms despite that treatment. Payers generally require conservative therapy to have been attempted before approving a procedural intervention.
Objective testing confirming dry eye. Document the results of one or more diagnostic tests, which may include Schirmer strips, ZoneQuick (phenol red thread test), rose bengal or lissamine green staining, fluorescein tear break-up time (TBUT), or direct tear meniscus measurement. Note that some tests may not be separately billable on the same date of service.
Informed consent. Document that the risks and benefits of punctal occlusion were clearly explained to the patient and that the patient consented to the procedure.

Avoiding Common Denials

Denial: Medical necessity not established. Ensure the record documents failed conservative therapy prior to the procedure. A patient who presents for plug insertion on the first visit without prior documentation of artificial tear use and continued symptoms is a denial risk.
Denial: Procedure billed during post-operative period. CPT 68761 carries a 10-day global period. A second plug insertion billed within 10 days of the first — for example, collagen plugs followed immediately by silicone — will be denied. Wait until the post-operative period has elapsed.
Denial: E&M billed same day without modifier -25. If an evaluation and management service is billed on the same date as CPT 68761, modifier -25 must be appended to the E&M code, and the E&M must be separately documented as a distinct, significant service.
Denial: Incorrect or unrecognized modifier. Confirm modifier requirements with each payer before submitting. Applying -50 when a payer requires E-codes, or vice versa, is a common and avoidable error.

Quick Reference

CPT Procedure Code

68761 — Closure of the lacrimal punctum by plug, each

Primary ICD-10 Diagnosis Codes

H04.121 — Dry Eye Syndrome, right lacrimal gland
H04.122 — Dry Eye Syndrome, left lacrimal gland
H04.123 — Dry Eye Syndrome, bilateral

Punctum Identifiers

E1 — Upper lid, left
E2 — Lower lid, left
E3 — Upper lid, right
E4 — Lower lid, right

Key Modifiers

–25 — Separately identifiable service, same day
–50 — Bilateral procedure
–51 — Multiple procedures
–RT / -LT — Right/left eye laterality

Supply Codes

A4263 (HCPCS) or 99070 — Medicare bundles the supply into the procedure fee; some private payers may accept a separate supply code.

Download the Lacrivera Billing Quick Reference Card for a printable summary of the most commonly referenced codes.

The information in this guide is believed to be accurate but is not intended to serve as a comprehensive authority on billing procedures. Always refer to official documentation from Medicare and your patients’ insurance carriers.