Ophthalmology and Optometry Coding Alert

Assign 57, not 25, for E/M prior to a major surgical procedure

Modifiers 24, 25 and 57 all have one special talent--allowing you to code an E/M service on the same day as (or during the global period of) a procedure. But they are not interchangeable, and to avoid denials you need a foolproof method for choosing the correct one.

Ask yourself these questions to decide which modifier will provide the carrier with an accurate picture of the E/M service.

Question 1: Does the E/M follow another service?

When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code. By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the E/M service is not included in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Remember: You cannot bill separately for E/M-related services during the global period, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. The global surgical package includes routine postoperative care during the global period.

Example: The ophthalmologist performs PRP (67228, Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]) on the right eye. Within the 90-day postoperative period, the patient complains that the vision in his left eye has become blurry.

The ophthalmologist performs an evaluation for this new, distinct problem (that is, the blurred vision in the left eye is unrelated to surgery in the right eye). The physician discovers that the left eye now has bleeding vessels (362.81, Retinal hemorrhage), which must be treated. In this case, append modifier 24 to the office visit during which the ophthalmologist assesses the second eye.

Question 2: Was it a 'major' or 'minor' procedure?

When the surgeon decides to perform another procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately.

Depending on the length of the procedure's global period, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code, says Karla Hastings, CPC, coder in the Central Billing Office of the department of ophthalmology at Indiana University.

Clue: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor
procedure, including those with zero, 10 or "XXX" global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CCP, coding specialist in Marietta, Ga.

Modifier 24: Conditions for Use

When you report modifier 24, the E/M service must meet these criteria:

• The E/M service occurs during the postoperative period of another procedure.
• The current E/M service is unrelated to the previous procedure.
• The same physician (or tax ID) who performed the previous procedure provides the E/M.

Note: This is true even if the two physicians have different specialties or sub-specialties, says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif. If the comprehensive ophthalmologist who performs a cataract surgery refers the patient to a retinologist in the same group for the evaluation of a retinal detachment, modifier 24 is still necessary. Medicare does not make a distinction between subspecialties or use of diagnosis codes.

Stick With Modifier 57 for 90-Day Globals

When the surgeon decides to perform major surgery (that is, a surgery with a 90-day global period) and provides the surgery that day or the next day, you should append modifier 57 to the E/M code, Hastings says. You can find Medicare's guidelines for modifier 57 outlined in the Medicare Carriers Manual (section 15501.1).

Example: Upon examination, the surgeon finds that a patient has a retinal detachment and schedules immediate surgery for repairs. Although the global surgical packages for 67101-67112 (Repair of retinal detachment ...) include one presurgical E/M service, in this case the office visit led to the decision to perform surgery. Therefore, you may report it separately with modifier 57 at the level supported by documentation.

Modifier 25: Conditions for Use

When you append modifier 25, the E/M service must meet these requirements:

• The E/M is significant and separately identifiable from any "inherent" E/M component included with other services/procedures you report on the same day. The office visit is not merely preoperative in nature or an integral part of the minor procedure.

• The E/M may be related or unrelated to other procedures/services you report on the same day.

• The service/procedure the surgeon provides on the same day as the E/M service should have a zero, 10 or "XXX" global period.

• The same physician bills the E/M and other procedures/services on the same day.

Modifier 57: Conditions for Use

To properly append modifier 57, remember these points:

• The E/M service must occur the day of or the day before a major surgical procedure (a procedure with a 90-day global period).

• The E/M service must prompt the surgical procedure that follows.

• The E/M service must be related to the procedure that follows.

• The same physician (or tax ID) provides the E/M service and the surgical procedure.

You should report both the surgical procedure (the appropriate code from the 67101-67112 series) and the examination that led to the decision to perform the surgery (for example, 99214). You should append modifier 57 to 99214 to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package for the retinal detachment repair, leading to a loss in reimbursement. Without the modifier, the visit will appear to be the preoperative visit that is included in the global surgical package. However, when you correct your claim by appending modifier 57, you should be paid for the visit. Many Medicare carriers have a dedicated review line that you can call to add the missing modifier, and payment is usually processed between 10 and 14 days.