Ophthalmology and Optometry Coding Alert

HCFA has temporarily suspended many of the edits in version 6.3 of the national Correct Coding Initiative (CCI). These edits had bundled more than 800 procedural codes with evaluation and management (E/M) codes, taking the coding world by surprise when they were issued last fall. The suspension, issued Jan. 26, is retroactive to Oct. 30, the date the 6.3 edits were issued.

The bundling of the E/M codes with diagnostic and radiological procedures required ophthalmology coders to use modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) when the E/M service represented a separate and significant service. HCFA now wants to educate the physician and coding community as to what a separate and significant service really is, says Linda S. Dietz, ART, CCS, CCS-P, coding specialist with CCI. They want to do some education on how to use the -25 modifier, Dietz says.

The suspension of the edits does not mean ophthalmologists can add 99211-25 (established patient) each time they perform a scan. If you have submitted claims that were rejected due to the edits, you should look at these claims and see if modifier -25 applies, Dietz says. If it does, then resubmit the claims, she says. If it doesnt, then we would not expect that claim to be resubmitted. Correct coding dictates that you cannot bill for a service that was not performed. Modifier -25, when appended to an E/M code, is defined as representing a service that is significant and separately identifiable from another service or procedure. The edits have been temporarily suspended, but that doesnt mean we dont expect correct coding, Dietz says.

A-scans and B-scans (76506-76536), as well as the rarely performed prescription for an artificial eye (92330-92335), were initially bundled into the eye exam and E/M services codes when performed on the same date of service. You still should not bill for these with an E/M service or an eye code unless a separately identifiable service is performed, and in that situation you should append modifier -25 to the E/M or eye code.

An example of when an office visit could be billed in addition to an A-scan is when the ophthalmologist sees the patient for the initial visit in which the decision for cataract surgery is made, and the A-scan is done on the same day. You would then code the physician visit with modifier -25, and also bill the A-scan. But an office visit could not be billed with the A-scan when, for example, the patient is asked to come back another day for an A-scan, and the technician performs the scan but no other service is rendered. Do [...]