Ophthalmology and Optometry Coding Alert

Before you file a claim with modifier -25 appended to the E/M service with the procedure for plug insertion, make sure your claim separately identifies the two services.
 
For hassle-free -- and denial-proof -- claims, use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or service) following these expert billing rules:

1. Documenting Each Procedure Is Key

All carriers require clear documentation that shows the ophthalmologist has rendered a medically necessary, significant, separately identifiable office visit.  

"The most difficult issue surrounding modifier -25 is ensuring that the E/M service is truly separate and significant from other procedures performed on the same service date," says Cindy C. Parman, CPC, CPC-H, RCC, co-founder of Coding Strategies Inc., in Dallas, Ga. "Documentation must clearly support the surgical procedure and the patient evaluation as separate services, and the medical necessity for a separate visit must be clearly stated." An excellent way to achieve this is to separate the documentation for each service.

Page 1 -- Visit Documentation. At a minimum, this documentation should include the patient's chief complaint; history of present illness; review of system(s) (or at least of the system complaint); a relevant past, family and social history (PFSH); and an appropriate related system examination and medical decision-making documenting the physician's impression and treatment plan.

Page 2 -- Minor Procedure Documentation. Be sure the doctor includes the patient's name, date, type of procedure and instrumentation, and medications or anesthetics used. Don't let the ophthalmologist get away with briefly documenting the procedure in the E/M report -- the carrier will not consider this sufficient documentation for separate reimbursement. A separate form titled "Operative Report" or "Procedure Report" is very helpful in documenting the two different services, says Maggie M. Mac, CMM, CPC, a health management consultant and national seminar leader for McVey Associates.

Be Proactive. Unless you file claims electronically, consider sending the carrier the documentation for both services as soon as you submit the claim. You will avoid delays that might surface if the carrier decides it is necessary to review the documentation before separately reimbursing each service. If the carrier denies the two separate procedures, use your documentation to appeal the claim. A brief cover letter explaining the medical necessity of performing the E/M service is very helpful.

Avoid. Don't append modifier -25 just because you documented "visiting with" or "speaking to" a patient before a procedure. To bill with modifier -25, make sure the E/M service can stand alone as a distinct procedure.

2. Linking Pertinent Diagnoses Is a Must

Link the diagnosis code for the sign or symptom that brought the patient to the office to the E/M service. Link the diagnosis code for the condition the physician found and treated to the minor procedure. Based on these requirements, you may be able to link the same diagnosis code to each service -- and in certain situations, this is correct coding.

CPT states that an E/M service may be prompted by a symptom or condition that leads to a diagnosis that  requires a procedure -- but the procedure must be separate from any procedure your physician completed for the initial symptoms or conditions. You don't necessarily have to have a separate diagnosis to have a separate procedure. Justifying use of modifier -25 -- and separate payment for each service -- is easier, however, when you can link each code to a separate diagnosis.