Ophthalmology and Optometry Coding Alert

Ophthalmologists should be on alert for another possible change to modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Already there is a change in CPT 2000 modifier -25 must be used with the office visit when a starred procedure (minor surgery such as epilation) is performed. Now a proposal is on the table to require the use of modifier -25 with services that dont have global periods. Under current Health Care Financing Administration (HCFA) policy, modifier -25 is applicable only to codes with global periods.

HCFAs concern, as stated in the revisions to Medicares payment policies for 2000, published in the Federal Register (Nov. 2, 1999), is that physicians will report an evaluation and management (E/M) service for every procedure. We proposed that, for selected procedures that have no global period, when a significant, separately identifiable E/M service is furnished at the same time by the same physician, the physician must append to the E/M service code the modifier -25, the Federal Register notice states. The basis for this policy is that, because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record. In other words, we want to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself.

But are the eye codes (92002-92014) the same as E/M codes for the purposes of modifier -25? This is confusing, and HCFA hasnt resolved it yet. Now you do not have to use modifier -25 when using an eye code and a diagnostic procedure. But by October 2000, when HCFA issues coding edits related to a new modifier -25 policy, it will be resolved.

Several commentators cited particular examples of diagnostic and treatment situations in which the E/M service and the procedure may be reported without the need for appending modifier -25, the Federal Register notice states. These examples are services represented by ophthalmology E/M codes 92002 through 92014 that result in the decision to perform a visual field examination (92081-92083) or a fluorescein angioscopy (92235) and ophthalmology services that do not have a global period and, therefore, an E/M service would always be performed. HCFAs response to these comments: We will take these comments into consideration when we develop correct coding edits based on the coding instruction related to the use of modifier -25.

What are coders actually doing? They are using modifier -25 on the office visit code or the eye code both are technically E/M codes to indicate that the E/M service or eye code service is separate. For example, a patient comes in for a glaucoma check. During the visit, the patient complains of foreign body sensations.

The ophthalmologist determines the patient needs lashes epilated (67820*-67825*). The office visit or eye code would be documented at the appropriate level with a modifier -25 to designate a separate problem and service. Although the descriptor for modifier -25 specifically says that two separate diagnoses are not required, it is recommended that two separate diagnoses be used and that there be two different ICD-9 codes.

When there arent two separate diagnostic conditions as presented in the above example, use the ICD-9 code for the symptom as the reason for the visit and the definitive diagnosis found upon examination as the reason for the minor procedure performed, explains Lise Roberts, vice president of Health Care Compliance Strategies, a coding, reimbursement and compliance consulting company in Jericho, N.Y.

Vickie Wadsworth, office manager and billing manager for Northern Wyoming Ophthalmology in Cody, Wyo., agrees. If we do a minor procedure, we use modifier -25 on the E/M visit, she says. If we use an eye code and a minor procedure, we use modifier -25 on the eye code. Wadsworth adds that she uses modifier -25 in these situations whether the payer is Medicare or commercial. I do it out of habit on all, she says. But, there is one exception. In Wyoming, Medicaid doesnt recognize any modifiers so she doesnt use modifier -25 on such claims. She still gets paid for both codes, however.