Ophthalmology and Optometry Coding Alert

Modifier -57 is the better bet for more intensive services

If your ophthalmologist provides an evaluation and management service that leads to the decision to perform a major surgery on the same day or the day before, be sure to append modifier -57 to the E/M code. Otherwise, payers could bundle the evaluation into the surgery and deny your practice legitimate compensation by misinterpreting the service as preoperative.

3 Conditions Govern Your -57 Use

To append modifier -57 (Decision for surgery), the services the surgeon performs must meet three conditions:

1. The E/M service must occur on the same day of or the day prior to the surgical procedure.

2. The E/M service must have directly led to the surgeon's decision to perform surgery.

3. The surgical procedure following the E/M must have a 90-day global period (that is, it must be a "major surgical procedure").

CPT doesn't have a set time frame for pre- and post-operative services. Medicare, however, directs carriers to "[p]ay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure," according to the Medicare Carriers Manual, section 15501.1. Most private payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Sandra Zarowitz, patient accounts manager at the VMR Institute, a practice specializing in laser therapy and surgery of the vitreous, macula and retina, in Huntington Beach, Calif.

You can also append modifier -57 to the eye examination codes (92002-92014, Ophthalmological services: medical examination and evaluation ...), Zarowitz says.
Experts say: Be on the lookout for laser procedures. Ophthalmologists commonly perform YAG laser capsulotomy (66821), focal laser treatments (67210) and pan-retinal photocoagulation (67228) on the same day as an evaluation. An ophthalmologist typically will not take a patient to an OR or ASC setting on the same day as an evaluation, unless the patient has an urgent retinal condition or injury due to trauma, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

For example: During a consultation, the ophthalmologist determines he needs to repair a detached retina that day. The procedure contains elements of 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling and/or removal of lens by same technique).

Because the detached retina repair is a major procedure, you should append modifier -57 to the E/M service code (99241-99245 for consultations), and documentation should specifically note that the E/M service resulted in the decision for surgery.

Why? Medicare considers the physician's evaluation of the problem and decision to perform major surgery as services outside of the global surgical package and greater than the preoperative service that is included in the package. To pay for that physician value, Medicare created  modifier -57 so the physician could identify the service and be properly reimbursed.

Start Global 1 Day Prior to Procedure

The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself and includes one preoperative workup prior to surgery. During this workup, the surgeon will discuss the procedure with the patient and answer any questions.

The global surgical period does not include visits that are medically necessary to make sure that a comorbidity will not prevent the patient from being able to undergo surgery.

Therefore, payers will bundle any E/M service the surgeon provides on the same day as, or the day before, a major procedure to the procedure itself, says Julia A. Appell, CPC, a coder in South Bend, Ind.

If the surgeon has already scheduled surgery, and then provides a final E/M service prior to surgery, you cannot charge separately for the service.

For example: The surgeon schedules cataract surgery for a patient. On the day prior to surgery, the surgeon meets with the patient for a final evaluation, to answer any questions the patient has and to provide additional instructions for recovery.
 In this case, you cannot charge separately for the E/M service. Because the surgeon already decided to perform surgery at a previous encounter - and because the E/M service occurs within the global period of the surgery - you should bundle this final presurgery E/M service into the cataract surgery.

Don't try to "cheat": Merely scheduling pre-op services two or more days before surgery will not necessarily make the services payable.
 
Insurers may consider such services to be "screening" exams unless there is some specific indication, such as hypertension or diabetes.