CPT Code 68801

CPT code 68801 is for the procedure of dilating the tear duct opening.

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What is CPT Code 68801

CPT code 68801 is used to denote a medical procedure that involves dilating the opening of the tear duct. This procedure is typically performed to address issues related to tear drainage, such as blockages or narrowings that can lead to discomfort or excessive tearing.

Does CPT 68801 Need a Modifier?

For the CPT code 68801 (Dilate tear duct opening), several modifiers may be applicable depending on the specific circumstances of the procedure. Here is an ordered list of potential modifiers and the reasons for their use:

1. -50 Bilateral Procedure: This modifier is used if the dilation of the tear duct opening is performed on both eyes during the same operative session. It is important to check payer policies as some may require two separate line items with -RT and -LT instead of -50.

2. -RT Right Side and -LT Left Side: These modifiers specify which eye underwent the procedure. -RT is used for the right eye and -LT for the left eye. These are used when the procedure is performed on only one eye or when each eye is billed separately.

3. -51 Multiple Procedures: This modifier is used if the dilation of the tear duct opening is performed in conjunction with other distinct procedures during the same surgical session. It indicates that multiple procedures were performed, and it may affect reimbursement depending on payer rules.

4. -52 Reduced Services: If the procedure was partially reduced or eliminated at the physician's discretion, this modifier would be appropriate. It indicates that the service level has been altered from the usual.

5. -53 Discontinued Procedure: Applied when a procedure is terminated after initiation due to extenuating circumstances or those that threaten the well-being of the patient. It is important for documenting and billing a procedure that was started but not completed.

6. -73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to Anesthesia Administration: Use this modifier when the procedure is discontinued in an outpatient or ASC setting before the administration of anesthesia.

7. -74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Anesthesia Administration: This modifier is used when the procedure is discontinued after anesthesia is administered but before the procedure is performed in an outpatient or ASC setting.

Each modifier has specific guidelines for use, and the choice of modifier can affect reimbursement. It is crucial to document the circumstances accurately and choose the appropriate modifier to ensure proper billing and to avoid claims denials. Always verify with specific payer policies as they can vary significantly.

CPT Code 68801 Medicare Reimbursement

CPT code 68801, which pertains to the dilation of the tear duct opening, is typically covered and reimbursed by Medicare when deemed medically necessary. The reimbursement for this procedure, however, can vary based on geographic location and the setting in which the procedure is performed (e.g., outpatient hospital, physician's office). To determine the exact reimbursement amount, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the Centers for Medicare & Medicaid Services (CMS) website or through Medicare Administrative Contractors (MACs) that manage claims and payments in specific regions.

Are You Being Underpaid for 68801 CPT Code?

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