Ophthalmology and Optometry Coding Alert

When an ophthalmologist performs an E/M service and a procedure on the same patient during the same encounter, you may be able to report the E/M service using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Or you may not.

To rightfully code an E/M-25, you must prove that the E/M is a separate service and is not an inherent component of a same-day procedure. Follow this advice to find out when to report an E/M with modifier 25, and when to leave the E/M off the claim.

The basics: "Coders should use modifier 25 when a significant, separately identifiable E/M service is performed by the same physician at the same face-to-face encounter as a procedure or other service," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M were truly separate, Brink says.

All procedure codes have an inherent E/M component, and the physician must go beyond that to justify a separate E/M. In addition, the E/M service must also meet medical-necessity criteria.

Example: An established patient with dry eye syndrome reports to the ophthalmologist for a scheduled punctal plug insertion. After discussing the procedure with the patient and answering a few questions, the ophthalmologist inserts a collagen plug into the patient's right lower puncta.

In this instance, the ophthalmologist does not perform a significant, separate E/M. The patient reported with a set appointment for the plug insertion and already had a diagnosis. On the claim, report the following:

• 68761 (Closure of the lacrimal punctum; by plug, each) for the insertion

• modifier E4 (Lower right, eyelid) linked to 68761 to show the location of the plug insertion

• 375.15 (Tear film insufficiency, unspecified) linked to 68761 to represent the patient's condition.

Now check out this example: A patient complaining of eye pain reports to the ophthalmologist. The ophthalmologist performs a review of systems; a check of past, family and social history; a problem-focused history; and a problem-focused exam on the eye, which reveals a conjunctival foreign body (FB). The ophthalmologist then removes the FB.

In this instance, the ophthalmologist performed an E/M prior to performing the procedure.

On the claim, you should report the following:

• 65205 (Removal of foreign body, external eye; conjunctival superficial) for the removal

• 930.1 (Foreign body in conjunctival sac) linked to 65205 to represent the patient's condition

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision- making) for the E/M service

• modifier 25 linked to 99212 to show that the E/M and plug insertion were separate services

• 379.91 (Pain in or around eye) linked to 99212 to represent the patient's eye pain.

As evidenced in the above example, you don't need a diagnosis code for a separate problem to code an E/M service with modifier 25, says Leslie Bowers, coder at Bay Ocean Medical. Sometimes, the circumstances justify a procedure and a separate E/M for the same complaint.

A good rule for modifier 25 claims is "if an E/M service was necessary for the physician to make a medical decision to perform the procedure -- and he had to take a history, perform an exam and come to a medical decision to perform the procedure -- then a separate E/M can be charged," Brink says.

But when the doctor asks a few incidental questions of the patient prior to the procedure, as is the case with most encounters, you should report the procedure code only.