CPT Code 68816

CPT code 68816 is a medical procedure code for probing a nasolacrimal duct using a balloon.

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What is CPT Code 68816

CPT code 68816 is a medical procedure code that describes the probing of the nasolacrimal duct with a balloon catheter. This procedure is typically performed to address issues such as blockages or obstructions in the nasolacrimal duct, which can affect tear drainage from the eye to the nasal cavity. The use of a balloon catheter helps to widen the duct and facilitate better drainage.

Does CPT 68816 Need a Modifier?

For the CPT code 68816 (Probe of nasolacrimal duct with or without irrigation, with balloon dilation), 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. -26 Professional Component: This modifier is used when only the professional component of the procedure is being billed because the provider did not own the equipment used for the procedure or was not responsible for the facility fees.

2. -50 Bilateral Procedure: If the procedure is performed on both sides, on the same day, this modifier should be used to indicate a bilateral procedure.

3. -51 Multiple Procedures: This modifier is used when multiple procedures are performed during the same surgical session. It helps to adjust the reimbursement for the additional procedures, which are typically paid at a reduced rate.

4. -52 Reduced Services: If the procedure is partially reduced or eliminated at the physician's discretion, this modifier should be applied to indicate that the service provided was less than the usual.

5. -53 Discontinued Procedure: Use this modifier if the procedure was started but discontinued due to reasons not related to the patient's health.

6. -54 Surgical Care Only: When only the surgical part of the procedure is performed by the physician, and post-operative management is handled by another provider, this modifier should be used.

7. -55 Postoperative Management Only: This modifier is used when the provider is only responsible for the postoperative management of the patient.

8. -56 Preoperative Management Only: If the provider only performed the preoperative care and did not perform the surgery, this modifier should be applied.

9. -59 Distinct Procedural Service: This modifier indicates that a procedure or service was distinct or independent from other services performed on the same day. It is used to signify that a procedure is not normally reported together but is appropriate under the circumstances.

10. -76 Repeat Procedure by Same Physician: This modifier is used if the same physician had to repeat a procedure on the same day during a separate encounter.

11. -77 Repeat Procedure by Another Physician: Use this modifier when a procedure is repeated by a different physician on the same day.

12. -78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: This modifier is used when a return to the operating room is required for a complication resulting from the original procedure.

13. -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: If a different procedure is performed by the same physician during the postoperative period of the first procedure, this modifier should be used.

14. -80 Assistant Surgeon: Used when an assistant surgeon is present during the procedure.

15. -81 Minimum Assistant Surgeon: This modifier is used when an assistant surgeon participated to a minimal extent.

16. -82 Assistant Surgeon (when qualified resident surgeon not available): This modifier is used specifically when an assistant surgeon is necessary and a qualified resident is not available.

17. -AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: This modifier is used when one of these non-physician practitioners assists at surgery.

Each modifier has specific guidelines for use, and it's important to verify with payer policies to ensure correct application and compliance with billing requirements.

CPT Code 68816 Medicare Reimbursement

The CPT code 68816, which describes probing of the nasolacrimal duct with balloon catheterization, is a procedure that can be reimbursed by Medicare. However, the reimbursement for this code can vary based on the geographic location and the setting in which the procedure is performed (e.g., outpatient hospital, physician's office).

To determine the exact reimbursement amount for CPT code 68816 under Medicare, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the Centers for Medicare & Medicaid Services (CMS) website. This schedule provides detailed information on the reimbursement rates for all CPT codes based on the specific locality.

Additionally, it's important to verify coverage and any specific billing guidelines with the local Medicare Administrative Contractor (MAC) as there might be regional variations or additional requirements to qualify for reimbursement.

Are You Being Underpaid for 68816 CPT Code?

Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately detecting underpayments. With the capability to read your contracts and identify discrepancies down to specific CPT codes, such as 68816 for probing a nasal duct with a balloon, RevFind ensures that every claim is thoroughly scrutinized by individual payer. Schedule a demo today to see how RevFind can help secure the payments you are entitled to.

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