Ophthalmology and Optometry Coding Alert

You’ve coded what you’re sure is a bulletproof claim for an E/M code and punctal plug insertion. You were sure to append modifier 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) to the E/M code to show that it was separate from the procedure. Your carrier, however, denies payment for the E/M service. To ensure that you boost your odds of collecting for both, check these essential tips.

Remember: The National Correct Coding Initiative bundles the E/M codes (99202-99215) into the punctal plug insertion code, but you can override the edit with a modifier if your documentation demonstrates the separate nature of the two services.

1. Verify Encounter Meets Modifier 25 Criteria

You should first check that your chart note supports billing the E/M with modifier 25. Every procedure has a small E/M component built into it to represent the preoperative work associated with rendering a procedure. So you must show that you performed a significant, separate service from the procedure or other service.

Medical necessity must exist and be documented to support the performance of an E/M service. This could be the result of an established patient with new symptoms or worsening symptoms for whom a new exam and medical decision-making are necessary.

Example: A patient reports dry, itchy eyes and generalized pain. The ophthalmologist performs a complete eye exam — separate from the procedure — to rule out other causes, and diagnoses dry eyes. The physician places collagen punctal plugs in the two lower puncta to see if this resolves the problem.

Report 68761 (Closure of the lacrimal punctum; by plug, each) on two lines and append E2 (Lower left, eyelid) and E4 (Lower right, eyelid). For example, you would report 68761-E2, 68761-51-E4 along with the most appropriate diagnosis code based on the documentation. Also report the appropriate-level E/M service with modifier 25 and link it to the appropriate diagnosis code (such as H04.123, Dry eye syndrome of bilateral lacrimal glands).

Tip: When your chart note’s E/M documentation can stand on its own, fight for modifier 25 payment if no carrier policies disallow the particular code combination. You don’t have to write the notes on a separate sheet, but visually separating the services or service and procedure will help show you whether the E/M is separately reimbursable.

2. Read the Payer’s Rules

Some insurers will not pay for an E/M service in addition to certain procedures or other E/M codes, regardless of your documentation. And if your contract specifies these restrictions, you shouldn’t waste time appealing the decision.

Better method: Know your payers’ rules. If your contract includes rules that require you to report services differently from CPT^® guidelines, you must follow them. But make sure to address these variations when your contract comes up for renewal. Non-Medicare payer bundles vary across the country.

3. Involve Others in Across-the-Board Rejections

But how do you know when a payer’s denials have gone from contract-approved denials to inappropriate activity? If an insurer never pays a modifier 25 service, you should find out why, experts advise. Insurers should recognize that an ophthalmologist may sometimes have to provide a separate service.

If a payer consistently rejects modifier 25 claims, raise the ante. Talk to the medical director, and involve your local medical board when reviewing the policy.