CPT Code 68761: Punctal Plug Billing and Reimbursement Guide for 2026

What Is CPT Code 68761?

CPT code 68761 is the procedure code for closure of the lacrimal punctum by plug, each. It reports the insertion of a small plug into the tear duct opening on the eyelid margin to block tear drainage and treat dry eye syndrome. The code is billed per punctum, carries a 10-day global surgical period, and applies to all plug types, including collagen, synthetic absorbable, and permanent silicone plugs.

Three things to know right away:

• Billed per punctum, not per eye. Each eye has two puncta (upper and lower), so a single eye can generate two line items when both are occluded. Multiple surgery reimbursement rules apply after the first plug.
• Plug supply is bundled. Medicare has included the cost of the plug material in the procedure reimbursement since 2002. You cannot bill the plug supply separately to Medicare or to the Medicare beneficiary.
• Modifier selection varies by payer. Medicare uses E-modifiers (E1 through E4) to identify which lid was treated. Some commercial payers require -RT/-LT or -50 for bilateral procedures instead. Confirming the correct modifier format before submitting prevents avoidable denials.

What Is CPT 68761 Used For?

CPT 68761 reports the insertion of a punctal plug into the lacrimal punctum, the tiny opening at the inner corner of the upper and lower eyelids where tears drain into the nasal passage. By physically blocking that drainage point, the plug keeps natural and artificial tears on the ocular surface longer, reducing the dryness, burning, and irritation associated with dry eye syndrome.

The procedure is one of the most commonly performed minor surgical interventions in ophthalmology and optometry practices. According to Medicare Provider Utilization data, punctal plug insertion ranks among the 15 most frequently performed ophthalmic procedures nationally. The clinical indications go beyond simple dry eye. Providers also use 68761 for patients with keratoconjunctivitis sicca, Sjogren syndrome, exposure keratopathy, filamentary keratitis, and persistent epithelial defects where tear conservation is part of the treatment plan.

The most common clinical workflow starts with a trial of collagen (temporary) plugs to confirm the patient tolerates occlusion without epiphora. If the trial is successful, the provider proceeds to semi-permanent or permanent silicone plugs. The same CPT code, 68761, applies regardless of plug material. You do not need to distinguish between temporary and permanent plugs on the claim.

One question we hear constantly from practice managers is whether the dilation of the punctum before plug insertion can be billed separately. It cannot. CPT 68801 (Dilation of lacrimal punctum, with or without irrigation) is bundled into 68761 per NCCI edits. Reporting both on the same date of service will generate an automatic denial.

Dry eye patients often receive diagnostic imaging during the same visit. Review the billing rules for CPT 92134 for OCT of the retina before combining procedures on the same claim.

How Much Does CPT 68761 Reimburse in 2026?

Under the 2026 Medicare Physician Fee Schedule, the national average reimbursement for CPT 68761 is approximately $140 in a non-facility (office) setting and approximately $97 in a facility setting. These figures use the 2026 non-qualifying APM conversion factor of $33.4009, as published in the CMS final rule for calendar year 2026.

The difference between non-facility and facility rates reflects the practice expense component. When the procedure is performed in the office, the practice absorbs overhead costs for staff, supplies, and equipment. In a hospital or ambulatory surgery center, the facility bears those costs, so the physician’s practice expense RVU drops accordingly.

Billing Scenario	Estimated 2026 Medicare Payment	Notes
Single plug, office (non-facility)	~$140	Paid at 100% of allowed amount
Single plug, facility	~$97	Lower PE RVU; facility absorbs overhead
Two plugs, bilateral (-50), office	~$210	150% of single plug (payer-dependent)
Four plugs, office (E1, E2, E3, E4)	~$280-$315	Multiple surgery rules apply (100/50/50/50)

For practices planning ahead, review the expected 2027 ophthalmology Medicare payment changes to see how fee schedule shifts may affect procedure-level revenue.

Actual payment varies by geographic locality. Medicare Administrative Contractors apply Geographic Practice Cost Indices (GPCIs) that adjust the national rate up or down by several percentage points depending on the practice’s ZIP code. Urban areas with higher cost of living typically see slightly higher reimbursement than rural regions.

Providers often come to us after realizing they have been leaving money on the table with punctal plug billing. The most common gap is not billing all four puncta when all four are occluded during a single visit. If the documentation supports medical necessity for all four, the provider is entitled to claim each one.

Which Modifiers Does CPT 68761 Require?

Modifier requirements for 68761 vary by payer, and applying the wrong modifier format is one of the most common and preventable reasons claims are denied. Here is how the major payer categories handle it.

Medicare E-Modifiers (Eyelid-Specific)

Medicare assigns E-modifiers to indicate exactly which punctum was treated:

• E1: Upper left eyelid
• E2: Lower left eyelid
• E3: Upper right eyelid
• E4: Lower right eyelid

Each plug is billed on a separate claim line with the corresponding E-modifier. This is the most granular approach and the one Medicare requires. When two or more puncta are occluded at the same visit, multiple surgery rules apply. The first line is reimbursed at 100% of the allowed amount, and each additional line is reimbursed at 50%.

Commercial Payer Modifiers

Many commercial payers do not recognize E-modifiers. Instead, they require:

• -RT (right eye) and -LT (left eye) for unilateral procedures
• -50 for bilateral procedures performed during the same session
• -51 for multiple procedures on the same anatomical side

How to bill correctly every time:

• Check the payer’s modifier policy before the first claim submission
• Use E-modifiers for Medicare and Medicare Advantage plans
• Use -RT/-LT or -50 for commercial payers that reject E-modifiers
• Append -25 to the E/M code if a separately identifiable office visit is performed on the same day as the plug insertion
• Never append -51 and -50 to the same line
• Confirm modifier preferences with each state Medicaid program, as requirements differ

Across the billing companies we vet, a recurring pattern is commercial payers denying 68761 claims because the practice submitted E-modifiers when the payer’s system only accepts -RT/-LT. The fix is simple, but it requires verifying payer preferences before the claim goes out, not after the denial comes back.

Which ICD-10 Codes Support CPT 68761?

A valid ICD-10 diagnosis code is required on every 68761 claim. Selecting a code that does not support medical necessity for punctal occlusion is a common cause of denial.

The H04.12x series provides the most direct diagnostic support:

• 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

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

• H16.109 – Unspecified superficial keratitis, unspecified eye
• H16.229 – Keratoconjunctivitis sicca, not specified as Sjogren
• M35.01 – Sjogren syndrome with keratoconjunctivitis
• H04.129 – Dry eye syndrome of unspecified lacrimal gland
• H16.141/H16.142/H16.143 – Punctate keratitis (right/left/bilateral)
• H18.831/H18.832/H18.833 – Recurrent erosion of cornea

Always use the most specific laterality code that matches the documentation. A claim submitted with an unspecified code (such as H04.129) when laterality is documented in the record may be flagged for review or denied outright by payers that enforce specificity requirements.

How to Bill Multiple Punctal Plugs on the Same Date

Billing multiple punctal plugs during a single encounter is where most coding errors occur. The key principle is that 68761 is billed per punctum, not per eye. Each eye has two puncta, so a maximum of four plugs can be billed in one session.

Step-by-step billing for four punctal plugs (all four puncta occluded):

• Bill CPT 68761 with modifier E4 (right lower lid) on line 1 at full fee
• Bill CPT 68761 with modifier E2 (left lower lid) and modifier -51 on line 2
• Bill CPT 68761 with modifier E3 (right upper lid) and modifier -51 on line 3
• Bill CPT 68761 with modifier E1 (left upper lid) and modifier -51 on line 4
• Place the highest-paying line first to maximize reimbursement under multiple surgery rules
• Ensure documentation supports medical necessity for occluding all four puncta

For payers that accept -50 instead of E-modifiers, the bilateral approach would be:

• Bill 68761 with -50 on line 1 (covers both lower puncta)
• Bill 68761 with -50 and -51 on line 2 (covers both upper puncta)

Some payers require a statement of medical necessity when more than two puncta are occluded on the same date. The most common documentation requirement is evidence that two-puncta occlusion was attempted previously and did not adequately control symptoms.

In our experience matching providers with billing partners, the practices that recover the most revenue from punctal plug procedures are the ones that maintain a modifier reference sheet for their top 10 payers. This eliminates guesswork at the time of claim submission and cuts first-pass denial rates significantly.

What Documentation Does Medicare Require for 68761?

Medicare considers punctal plug insertion medically reasonable and necessary when the following criteria are met and documented in the patient’s record:

• Symptomatic dry eye syndrome. The patient must have moderate to severe dry eye that has not responded adequately to conservative treatment such as artificial tears.
• Diagnostic testing. At least one objective test confirming aqueous tear deficiency must be documented. Accepted tests include the Schirmer test, tear break-up time (TBUT), and ocular surface dye staining with rose bengal, sodium fluorescein, or lissamine green.
• Slit-lamp examination. A biomicroscopy exam must be performed and documented.
• Failed conservative therapy. The record should show that artificial tear supplementation was tried and did not provide adequate relief before the provider moved to occlusion.
• Informed consent. Documentation that the risks and benefits of punctal occlusion were explained to the patient and that the patient consented to the procedure.

The standard clinical pathway that supports medical necessity looks like this: the provider documents dry eye symptoms, performs objective testing, prescribes artificial tears, reassesses at a follow-up visit, confirms persistent symptoms despite conservative therapy, performs a collagen plug trial, and then proceeds to semi-permanent or permanent plugs if the trial is successful. Each step must be documented in the medical record.

Common Denial Reasons and How to Prevent Them

The most common denial reasons for CPT 68761 claims fall into a handful of preventable categories. Knowing these patterns in advance saves the rework and revenue delay of appeals.

Denial Reason	Root Cause	Prevention
Medical necessity not established	Record lacks documentation of failed conservative therapy or objective testing	Document Schirmer/TBUT results and prior artificial tear use before the procedure
Procedure billed during post-op period	Second plug inserted within 10 days of first	Wait until the 10-day global period expires before billing a subsequent 68761
Modifier mismatch	E-modifiers sent to a payer that requires -RT/-LT/-50	Verify modifier preferences by payer before submission
E&M billed same day without -25	Office visit billed alongside 68761 without modifier -25	Append -25 to the E/M code and document that the visit was separately identifiable
Plug supply billed separately	Practice submitted a separate supply charge to Medicare	Do not bill plug supply (A4262 or A4263) to Medicare; it is bundled into 68761
Units billed instead of separate lines	Multiple plugs billed as units on a single line	Bill each punctum on its own claim line with the appropriate E-modifier

The most common issue we see providers run into is submitting 68761 with two units on a single line instead of splitting each punctum onto a separate claim line with its own modifier. Payers reject the units approach because the E-modifier cannot specify which punctum was treated when only one line exists. The fix is mechanical: separate lines, separate modifiers.

Frequently Asked Questions