Ophthalmology and Optometry Coding Alert

The five-digit CPT codes aren't the only part of your coding undergoing changes this year. If you don't pay attention to modifier changes, you'll be facing a slew of denials in the coming months.

Dig into the revisions CPT made to modifiers, including 22 and 59, with these expert highlights on what you need to know.

The requirements for modifier 22 will become much stricter in January when the modifier descriptor changes from "Unusual procedural services" to "Increased procedural services."

Old way: You have used modifier 22 when your ophthalmologist provided a service that was "greater than that usually required for the listed procedure." You may have submitted a written report explaining the reason why the modifier was appropriate in that particular clinical scenario.

For example, Nancy LaVergne, CPC, OCS, CAPPM, coder for Jackson Eye Associates in Missouri, says she always attached an operative report where the physician documented the reason that this procedure was more complicated or took longer. "He may say something like 'It took an additional 30 minutes to do this procedure due to the complications mentioned above,' " she says.

New way: Your physician's work must be "substantially greater than typically required," says the 2008 CPT guidance about modifier 22. Your documentation must support the "substantial additional work." You must also list the reasons why the ophthalmologist had to work harder, such as increased intensity, added time, the procedure's technical difficulty, severity of the patient's condition, or physical and mental effort required.

The new language sounds a lot tougher than the old wording, but you'll have to wait for guidance on what "substantially greater" means, says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders in Salt Lake City.

Now experts teach that you should use modifier 22 whenever the physician spends about 25 to 50 percent more time or effort than usual for a procedure. "I have always interpreted that this modifier should be used if the procedure was substantially greater, not just a little more difficult," LaVergne says.

The problem: There isn't now a written rule from CPT that explains what percentage of additional time qualifies a procedure for modifier 22 use. Keep in mind that you should not use time alone as the precipitator for using modifier 22. The additional work and difficulty warrant modifier 22 use, and the unusual additional surgical time will be an element of your supporting documentation.

"What's the difference in 'unusual' and 'increased'?" asks Dianne Wilkinson, RHIT, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

"Repeated reviews by Medicare have shown that doctors are not supporting modifier 22 well enough in their documentation," Wilkinson adds. So the CPT update is beefing up the documentation requirements to encourage you to do what you should already be doing, she adds.

Helpful hint: The new descriptor provides some great pointers on things to look for when you audit your use of this modifier, Wilkinson says.

You can now safely apply modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to staged or related procedures that were "planned or anticipated" at the time of the original surgery, not just ones that your ophthalmologist planned in advance. The CPT guidance for this modifier only referred to planned, not anticipated, services before Jan. 1.

Many coders were already using modifier 58 when the doctor only anticipated the possibility of surgery instead of planning it, Cobuzzi says. This change will just make those coders "more comfortable" with that use, she says.

"This modifier is also used when a more extensive than the original procedure has to be done, which is often used with glaucoma procedures," LaVergne says. "The physician will do one procedure to bring the pressure down, but if it does not work, he does a more extensive procedure, such as 66185 when 66180 has been done previously."

Also important: CPT 2008 adds "unplanned" to the descriptor for modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

High point: These changes should make deciding among modifiers 58, 76 (Repeat procedure or service by same physician) and 78 easier when your ophthalmologist has to perform a second procedure or service on a patient.

Although the modifier 59 descriptor (Distinct procedural service) doesn't change for 2008, the CPT guidance after the descriptor in the CPT manual offers new wording. The description now says "documentation must support" that there was a separate session or distinct service.

Cobuzzi says she's been teaching all along that your documentation must support modifier 59. "They're just clarifying it because there's been so much abuse on 59."

Additionally: CPT removes the wording "the physician may need," changing it to "it may be necessary," and replaces "by the same physician" with "by the same individual." Presumably, this clears up any questions as to whether you can use this modifier for services your nonphysician practitioners (NPPs) perform.