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 [...]