Ophthalmology and Optometry Coding Alert

When performing a minor procedure on the same day as an office visit, the ophthalmologist may be able to bill both the E/M code (99201-99215, 92002-92014) or consultations (99241-99245) in addition to the procedure code. When billing both codes, the ophthalmologist must append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, making sure to link the appropriate ICD-9 and CPT codes .

Separate the Office Visit From the Procedure

While the expanded definition of modifier -25 states that the diagnosis can be the same for the office visit and the procedure, two separate diagnoses may help clarify for the payer that the office visit is separate from the procedure. If the symptom that brought the patient in for the office visit is linked to the final diagnosis of the procedure, you often find that there are two separate diagnoses.
 
For example, a patient has a red, sore bump, and the physician after a history and examination determines it is a chalazion. The ophthalmologist may perform an incision and drainage/curettage of the chalazion during the visit, so you should append modifier -25 to the office visit with 379.92 (unspecified disorder of eye and adnexa; swelling or mass of eye) linked to the visit code. Bill the procedure code (67800-67805) with 373.2 (inflammation of eyelids; chalazion) linked to it.
 
In another example, a patient complains of a foreign-body sensation in one eye. The physician finds trichiasis and treats with epilation (67820*, correction of trichiasis; epilation, by forceps only). Append modifier -25 to the office visit with 379.91 (unspecified disorder of eye and adnexa; pain in or around eye) linked to the visit code, and link 67820* to 374.05 (other disorders of eyelids; trichiasis without entropion) or 374.00-374.04 for one of the trichiasis-with-entropion codes.

When To Bill for Procedures Only

If the office visit and the procedure are unrelated, it is important to bill them separately. For example, sometimes a patient has already been seen once for a chalazion, and the physician prescribes topical antibiotics and hot packs for several days instead of doing minor office surgery. In most cases, the chalazion will heal. In other cases, the patient will report that it has not healed in the expected time. These patients are usually scheduled to come back to the office for surgery.
 
Such return encounters do not involve a separate and identifiable visit in which a history, an examination and medical decision-making are involved. The determination to do the minor surgery if the chalazion did not resolve with medical intervention was made at the previous visit. Basically, the ophthalmologist enters the examining room, looks at the eyelid and performs the procedure. In such cases, bill the procedure only, not an office visit.
 
Another example involves the trichiasis patient. If the patient has recurrent trichiasis and comes to the office often for lash removal, just the epilation should be billed without an office visit code. The only exceptions to this are other diagnostic conditions for which the patient was being examined on that day or if the ophthalmologist performs a reassessment of alternative treatments for the recurrent trichiasis.

Separate Billing During the Postoperative Period

If the office visit and procedure are unrelated to the surgery, the ophthalmologist may bill separately for the office visits and procedures performed during the postoperative period. For example, a patient has cystoid macular edema (CME) after cataract surgery, manifesting itself as poor visual results. The CME (362.53) is most often treated by sub-Tenons injection of steroids, 67515 (injection of therapeutic agent into Tenon's capsule). The visit would be charted as unrelated to the cataract surgery and billed with modifiers -24 (unrelated evaluation and management service by the same physician during a postoperative period) and -25. Append modifier -79 (unrelated procedure or service by the same physician during the postoperative period) to 67515.

To Bill or Not To Bill

While it would be correct to bill 67515-79 and the office visit with modifiers -24 and -25, you may not want to bill anything for this patient. The patient is often unhappy because the ophthalmologist gave the impression that cataract surgery would be successful, and the patient feels it was not. The visual impairment is due to the CME, not the cataract surgery, but it will be enough of a challenge for you to explain that clinical fact. Consider that the patient may be displeased with the surgical result and also has the discomfort of CME. When you ask the patient for a 20 percent copayment for the office visit and injection, you could make matters worse.
 
For this reason, if you decide to bill for these services, it is of paramount importance that your patient under-stands that the CME is not the result of the cataract surgery. Explain that the affliction also occurs in patients who have never had the surgery. If you skip this step, you should be prepared for the negative public relations that the patient may broadcast.

Justify  Modifiers -24 and -25

Document your files carefully to justify modifiers -24 and -25. Many compliance consultants recommend using separate pieces of paper to document the office visit and the minor procedure, although this is not a Medicare requirement. You can even create a "minor procedure" form by making a dated entry for each procedure performed and documenting the procedure after a treat-ment plan has been devised for that particular office visit.
 
Ophthalmologists who use their own shorthand for documentation need to remember that words work best for  auditors. If the physician's notes are abstracted, the abstractor may not pick up on all of the details. This is particularly important when billing for both office visits and procedures.
 
The physician should write his or her notes in longhand instead of shorthand. Although you may understand what makes an office visit separate from a procedure, you must make sure an auditor will as well. If shorthand is the only way the physician is willing to document, prepare a standardized abbreviations list with  the abbreviations in the physician's own handwriting and a corresponding printed or typed explanation of those abbreviations. If your records are audited by an outside party at any time, you will be able to provide the auditor with the abbreviations list, which will assist in auditing the records fairly.