Ophthalmology and Optometry Coding Alert

Ophthalmology coders may have noticed that the very useful modifier -25 (for a separate service on the same day as a different service), as well as modifier -24 (for an unrelated service during the postoperative period), dont always work when they are used with the eye codes (92202, 92204, 92012, 92014) for non-Medicare patients. Thats because private HMOs choose, when it is in their best interest, to interpret CPT very literally. So while Medicare recognizes both of these modifiers when used with the general ophthalmological services codes, private insurance companies may not.

The reasoning used by private insurance companies lies in the definitions of the modifiers themselves:

Modifier -24 is for unrelated evaluation and management services by the same physician during a postoperative period. The definition continues: The physician may need to indicate that an evaluation and management services was performed during a postoperative period for a reason unrelated to the original procedure. To report this circumstance, physicians are instructed to add the -24 modifier to the appropriate level of E/M service.

Modifier -25 is for a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. This definition continues: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed."

Note: What has been happening with many private insurance companies (not Medicare) is that they are refusing to recognize the modifiers -24 or -25 when it is appended to an eye code. They are taking the fact that the definition specifically mentions applying these modifiers to E/M services, and relying on this to deny the added procedure code. Medicare, however, recognizes the modifiers whether they are attached to an E/M or an eye code.

We never use the modifier -25 on the eye codes, says Bobbie J. Williams, insurance and billing clerk for Richard Cape, MD, of Dyersburg, TN. The only modifier I use on the eye codes is -57 (decision for surgery), she adds.

Williams does use the eye codes, but not when she needs to use modifier -25. She follows this rule for commercial HMOs as well as for Medicare.

If the patient is having punctal plugs inserted, having visual fields done, or having fluorescein angiography, Williams would always use an E/M services code, with the modifier -25 on that code, and the procedure code with no modifier for whatever additional service was provided on the next line.

I use this as a rule of thumb for commercial HMOs, says Williams. The modifier -25 has never been denied when I use it with an E/M services code. Using it for Medicare as well is okay, but not necessary.

So, when is it okay to change the way you bill based on the payers willingness to recognize the modifiers?

Theres nothing wrong with using the eye codes and modifier -25 for Medicare, and using the E/M services codes and modifier -25 for commercial insurance, says Linda Atut, compliance manager for the Ophthalmology Department of the Loyola University Physician Foundation in Maywood, IL. As long as youre abiding by the payer guidelines, you are in compliance.

But Atut notes that it can be time-consuming to call payers to find out why they have rejected an eye code with a modifier -25, only to learn that you need to use an E/M services code with that modifier for that particular payer. Were a large group, and we cant make all the calls to all the payers, says Atut, whose department has 25 ophthalmologists. But she acknowledges that ophthalmologists who do try to chase down these calls, for the extra revenue that modifier -25 can bring in, are doing the right thing. We need all the optimum reimbursement we can get, she says. But you do need to have the staff to make those phone calls.

Finally, Atut warns that some payers simply limit payments on modifier -25, regardless of where you put it.

Modifier -25 Made Easier by CPT 1999

There is new text in the definition of modifier -25 in CPT 1999. It clarifies that there can be some connection between the two procedures or services reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided, CPT states. As such, different diagnoses are not required for reporting of the E/M services on the same date.

An example would be an E/M service that is connected to another procedure done at the same time. The patient complains of a scratchy feeling in the eye. The ophthalmologist does an exam and finds that the patient has an aberrant lash -- an eyelash which is growing towards the eyeball. The physician epilates the lash, a minor surgical procedure which is coded as 67820. The diagnosis is 374.05 (trichiasis) -- for the procedure, and for the office visit. That makes them connected. But you should still use the -25 modifier, so you can get paid for both the visit and the procedure. If you run into a payer who says theyre related, and therefore we wont pay for the visit -- and there are plenty of payers out there with that policy -- then you need a different diagnosis for the office visit. And actually, a different diagnosis is perfectly warranted. After all, the patient didnt walk into your office and say: I have trichiasis, forceps please. You needed to do an exam, take a history, and engage in medical decision-making. So the diagnosis code for the visit could well be 379.91 (pain in eye).