Ophthalmology and Optometry Coding Alert

Fortunately, you can use a modifier to separate the edits when warranted.

Although most ophthalmology coders think of the summer as a time when their codes are set for the year and they don’t have to worry about policy adjustments, the Correct Coding Initiative (CCI) is always ensuring that you stay on your toes.

CCI version 22.2, which went into effect on July 1, now bundles 99173 (Screening test of visual acuity, quantitative, bilateral) into the office-based E/M codes 99201-99215.

“This is not a surprise,” says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “Medicare typically has not paid for refractions so I’m not surprised they would limit the circumstances where they may pay for a screening test of visual acuity separate from the E/M.”

In addition, CCI now bundles 65760 (Keratomileusis), 65765 (Keratophakia), 65767 (Epikeratoplasty), and 65771 (Radial keratotomy) into 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report)

“The corneal topography would probably be performed prior to the procedures listed (not on the same day),” Mac says, “but for corneal topography done on the same day as the procedure, it is not surprising to see this bundled. I would hope that the RVUs associated with paying these procedures would be adjusted accordingly to include the work of the topography.”

 All of the new edits referenced above have an indicator of “1.”

Add Modifiers Only When Applicable

Typically, an indicator of “1” means that you can use a modifier to bypass the edits, particularly in cases when your documentation can prove that the bundled, or “column 2” service was a distinctly separate service. For instance, it would apply if you billed the column 1 code for the left eye and the column 2 code for the right eye. However, there’s more to separating the edits than just sticking a modifier on the column 2 code and moving on.

“CCI edits on CPT^® codes with an indicator of ‘1’ is not enough to support adding a modifier,” says Rae Freeman, RHIA, CDIP, CCS-P, senior consulting manager with Healthcare Coding and Consulting Services. “There must be documentation in the medical record to support all CPT^® codes that are coded and billed. If there is not, then a modifier would not be appropriate either.”

Use Modifier 25 for E/M Services Only

When most practices see a CCI edit, they immediately reach for modifier 59 (Distinct procedural service) and assume it will separate the edits without any further explanation. However, modifier 59 is only for procedures and services, and doesn’t apply to E/M codes. In addition, it is considered the “modifier of last resort” by Medicare and most other payers, and you should only use it when no more appropriate modifier applies.

 Therefore, if you encounter a situation when your E/M code is bundled into the procedure—for instance, 99213 is a component of 68200 (Subconjunctival injection)—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) would be a better route to payment, assuming your documentation can back it up.

“Modifier 25 is only applied to E/M codes and only if appropriate,” Freeman says. “The provider documentation has to show a significant, separately identifiable E/M service on the same day as the procedure or other service.  If it is documented, then modifier 25 would be applied to the E/M code.”

If your documentation only reveals the minor evaluation service that’s included in the injection, however, then you cannot support the requirement for a separately identifiable, significant service that modifier 25 requires.