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 [...]