Ophthalmology and Optometry Coding Alert

Fee Schedule proposal aims to revalue certain services when billed with modifier 25.

If you’re accustomed to collecting for both an E/M and conjunctival injections when performed on the same date, you may want to prepare for an adjustment—which will be necessary if CMS finalizes the 2017 Medicare Fee Schedule Proposal.

On July 7, CMS published the proposed fee schedule, and among the potential payment issues for 2017 is a provision that would cause the agency to scrutinize claims submitted with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

“Medicare claims data for CY 2015 show that 19 percent of the codes that describe 0-day global services were billed over 50 percent of the time with an E/M with Modifier 25,” CMS says in the proposed Fee Schedule. “Since routine E/M is included in the valuation of 0-day global services, we believe that the routine billing of separate E/M services may indicate a possible problem with the valuation of the bundle, which is intended to include all the routine care associated with the service.”

Based on that finding, CMS launched a review of the CPT^® codes that practices routinely report with an E/M and modifier 25, and the agency classified 83 of them as “potentially misvalued,” meaning CMS may adjust the payment model for these codes. “We identified 0-day global codes billed with an E/M 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary,” CMS explained when discussing how it created the list of potentially misvalued codes.

68200, 67810, 65205 and More Among the 83 Codes

Out of the 83 codes on CMS’s list, the following are the most relevant to ophthalmologists:

• 65205—Removal of foreign body, external eye; conjunctival superficial
• 65210—Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating
• 65222—Removal of foreign body, external eye; corneal, with slit lamp
• 67515—Injection of medication or other substance into Tenon’s capsule 
• 67810—Incisional biopsy of eyelid skin including lid margin 
• 67820—Correction of trichiasis; epilation, by forceps only
• 68200—Subconjunctival injection

Although the codes above are the most pressing for ophthalmology practices, there are even more codes on the list that will impact practices’ bottom lines if CMS goes through with the proposal, which could have a ripple effect throughout your reimbursements.

Potential explanation: Coding experts aren’t surprised that CMS is reviewing the use of E/M codes with foreign body removals. “Over the years, there has always been a move to deny the E/M when a patient presents with a foreign body in the eye,” says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “This is because the physician does not stop to do the components of an E/M service, but instead, gets the needed information from the patient as to how the problem occurred and then gets right down to examining the patient’s eye to relieve the pain and resolve the problem.”

This “workup” of obtaining some preliminary information is considered part of the surgical procedure and payment is built into the procedure for removal. Therefore, the E/M should not be separately billed, Mac says. “The payers do state that if it is necessary to do a complete E/M workup, the medical record must show the medical necessity for the E/M outside of the usual workup for the foreign body removal and this should be separately identifiable in the medical record,” she adds. “Then the E/M may be separately billed with modifier 25.”

Rule Could Prompt Denials If Finalized

At the moment, it remains unclear how CMS plans to implement changes to the 83 potentially misvalued codes on the list, but most analysts are not optimistic. “It’s possible that they payers will either pay for the E/M or the procedure, but not both, requiring the practice to appeal, supplying the notes to prove the E/M was a significant, separately identifiable E/M,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

“Denials would create two things for the payers,” Cobuzzi says. “First, some practices (about 50 percent historically) will not appeal the denials. And second, the other 50 percent will give the payers a chance to audit the documentation via the appeals and they can collect data on practice performance on the modifier 25 use and their documentation success and failure.”

The finalized fee schedule will be issued this fall, so keep an eye on Ophthalmology Coding Alert for more on this as CMS finalizes issues within the 2017 Fee Schedule.

Resource: To read the complete Proposed Fee Schedule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf.