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 not attempt to bill 99211 along with that A-scan. Modifier -25 should not be used; it is not a significant and separately identifiable service.

HCFA said some carriers computer systems are not accepting modifier -25 on the eye codes, so it does not plan to re-implement the edits with these codes unless the problem can be rectified. Still, you cannot bill for a service unless it was rendered: Correct coding should be your goal to avoid audits and fraud charges.

The temporary suspension means only that HCFA is giving you a chance to look at your claims again. Before using modifier -25, make sure the service is significant and separately identifiable from the procedure.

HCFA is reviewing the edits and may re-implement many of them as early as July 1, 2001. CCI version 7.1 is expected to be released April 1, 2001.

How to Refile Claims Refiling multiple claims per HCFA instructions to use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when justified can be made simpler by batch processing. Raequell Duran, president of Practice Solutions, an ophthalmology coding and compliance consultancy based in Santa Barbara, Calif., recommends the following method: 1. Create paper copies of corrected claims for each patient by printing the hard copy of the original claim, adding modifier -25, and attaching the original Medicare explanation of benefits (EOB) to each of the claims. Include chart notes so you dont have to go through the whole process again. 2. Send the batch with a letter that explains you were unaware of the required use of modifier -25. Also state in the letter appealing the denials that you are now seeking payment of these visits because they were the original date of determination that the patient needed surgery, which made the service separate and identifiable from the A-scan. Duran supplies a sample letter: Please find attached several claims that were denied due to the Correct Coding Initiative (CCI) bundles and the lack of modifier -25. We were unaware that the office visit codes had been bundled with 76519, and did not attach the required modifier when the claims were originally billed. I have enclosed the corrected claims, the original EOB and the chart notes that clearly show a significant and separately identifiable office visit was rendered in addition to the testing service. Please process these claims for payment. If your practice does A-scans the same day as cataract consultations, you may also want to add the following: In fact, all of the office visits were initial consultations to determine the need for surgery and in no way were integral to the testing services that were performed.