Ophthalmology and Optometry Coding Alert

Claims processing problem prevented modifier 25 from unbundling procedures, CMS says

Effective with the implementation of Correct Coding Initiative (CCI) version 19.3 on Oct. 1, 2013, the edits bundling CPT® codes 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) and 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) into hundreds of procedure codes are suspended retroactively to July 1, 2013.

On that date, CCI 19.2 bundled those two ophthalmological services codes, along with most of the evaluation and management (E/M) codes, into CPT® codes describing surgical services with global periods of 0, 10, or 90 days. These edits were based on the Medicare Claims Processing Manual, Section 40.3.B, said Niles R. Rosen, M.D., medical director of the National Correct Coding Initiative, in a letter to Michael Repka, M.D., medical director for governmental affairs for the American Academy of Ophthalmology, published on the AAO website.

However, many AAO members complained that appending modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period), 25(Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), and 57 (Decision for surgery) was not bypassing the edits as it should, noted Rosen’s letter.

Why? “CMS has determined that there is an electronic claims processing problem that is not allowing modifier 25 to bypass these NCCI edits,” says Rosen. “Resolution of the claims processing problem lies outside the NCCI program.”

The Multi-Carrier System “inadvertently omitted 92012 and 92014 from the E/M range of 99201-99499,” explains a CMS MLN Connects bulletin, “and is not allowing the use of separately billed modifiers 25, 24, and 57. This is causing claims to deny inappropriately when the modifiers are appended to these procedure codes.”

Until it can sort out the claims processing problem, NCCI is suspending these edits affecting 92012 and 92014 retroactive to July 1, the date they were put in force. The edits will likely reappear once the problem is resolved, says Rosen.

“Claims incorrectly denied because the claims processing system did not bypass an NCCI edits when modifier 24, 25, or 57 was appropriately appended to CPT® codes 92012 or 92014 when reported on the same date of service as a global surgery procedure may be resubmitted to the local A/B MAC after Oct. 1, 2013,” says Rosen.

However, resubmitting the claims may not be necessary: “CMS is correcting this issue and A/B Medicare Administrative Contractors [MACs] will reprocess all inappropriately denied claims by Nov. 15, 2013,” says the MLN Connects bulletin. Providers do not need to take any action in having their claims corrected.”

For more information: Read NCCI’s letter to the AAO at www.aao.org/aao/outofcs/wre/CMS_NCCI_letter.pdf. Read the MLN News bulletin at http://go.cms.gov/1gh21A6.