Ophthalmology and Optometry Coding Alert

When a patient comes to an ophthalmologist with a complaint, and the physician can resolve the problem that same day, there are two procedure codes that can be used: the surgery code and the office visit code. Under certain conditions, you can get paid for both of those codes, by using the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (decision for surgery).

Note: In this article the termoffice visit refers to the evaluation and management (E/M) services codes99201- 99215as well as the ophthalmic codes92002, 92004, 92012, 92014. Either of these can be billed in addition to minor surgery.

The main justification for billing both the minor surgery code and the office visit code is this: The ophthalmologist must provide a separate service for each code. Does this mean you have to have two separate diagnoses? It helps, according to billing experts. The key is good documentation by the ophthalmologist.

With coding for minor surgery, you have to work closely with the doctor, says Ramona Cosme, president of Ramco Medical Billing in Edison, NJ. Sometimes the ophthalmologist doesnt understand that its necessary to document all of the circumstances, and not just what is going on the superbill.

Using Modifier -25 Correctly

If the doctor provides a service having to do with another condition in addition to the minor surgery, modifier -25 should get the claim paid, explains Cosme, whose billing company files claims for 27 ophthalmologists. For example, lets say a patient comes in for an office visit, but is determined to have a chalazion. The ophthalmologist determines that it needs to be removed immediately, and excises it that day. So 67800 (excision of chalazion; single) gets checked off on the superbill; the biller then transcribes it onto the claim form.

Heres how Cosme would handle a typical claim form with only a minor surgical procedure code and no office visit indicated by the doctor.

1. Going back to the doctor. Lets say the patient has an ongoing condition, such as glaucoma, explains Cosme. I would see the 67800 on the claim, and because I am familiar with the billing, I remember this patient has glaucoma, and I would ask the practice if the doctor checked the patient for that. They say, I dont know, let me pull the chart. Then they come back and say, Yes, the patient was observed for glaucoma while he was there for the chalazion. Bingo. Theres the modifier -25. No, the patient might not have had any glaucoma symptoms at the time. But the ocular pressure is still there. It wouldnt be good practice on the ophthalmologists part not to check the pressure, says Cosme. If he documents this in the chart, then you can bill for the office visit.

Modifier -25 can be used on an E/M services code or an ophthalmic code, Cosme notes. Whats important is that you document the services provided in the chart.

2. Its a good idea to have a second diagnosis. Although the definition of modifier -25 was changed in CPT 1999 to exclude the requirement that there be a separate diagnosis for the office visit, most billers seem to feel more comfortable having a second diagnosis. We do a lot of punctal plugs, and always bill an office visit with the procedure, says Jennifer Hoover, bookkeeper for Finger Lakes Eye Center in Horseheads, NY. I always encourage our staff to use a second diagnosis. Hoovers software automatically puts the primary diagnosis on every line-item, so she uses an additional, secondary diagnosis for the office visit. Then Medicares computer, because of the modifier -25, jumps down to the secondary diagnosis on the office visit, she says. What does she use for the secondary diagnosis? Whatever other condition the patient came in with, Hoover explains. It may be nuclear sclerosis (366.16), ocular hypertension (365.04), or something else.

In the case of punctal plugs, Hoover uses 375.15 (tear film insufficiency, unspecified) for the diagnosis code for both CPT codes. There is another diagnosis code which could possibly be used for the secondary diagnosis on the office visit, says Hoover: 710.2 (Sicca syndrome). This is a more systemic diagnosis than 375.15; Medicare wont allow it as the primary diagnosis for punctal plugs. Weve never had a denial for punctal plugs and an office visit, says Hoover. So she recommends 375.15 as well as a secondary diagnosis code to get paid for office visits and punctal plugs.

Normally we dont have a problem getting a second diagnosis, says Jody Gustafson, billing clerk for the Erie Eye Clinic in Erie, PA. The only minor surgery that we dont even try to get an office visit with is foreign body removal.

(For more information on foreign body removal and office visits, see related box on this page.)

Tip: Sometimes, says Gustafson, the foreign body is there as a result of an accident. If the accident is work-related, she can then use 99058 for emergency services. This adds $72 to the foreign body removal fee, she explains. Under the states (PA) workmans compensation law, if a patient comes into the ophthalmologists office within 72 hours of an accident, then the coverage is workmans compensation. Medicare and most commercial payers, however, bundle 99058 into an office visit code.

A common situation that calls for modifier -25 at Gustafsons office is epilationremoval of an eyelash that is causing irritation to the eye. If you want to get paid for the office visit in addition to the epilation, you almost always have to have separate diagnoses, she says. Lets say the patient has glaucoma, and comes in with the trichiasis. The doctor will check the glaucoma as well. What if the patient comes in for a glaucoma check and mentions to the ophthalmologist that there has been an irritation? The doctor looks and sees trichiasis, and performs an epilation. In this case, the office visit and the epilation would both be billable. As long as theyre both documented, you can bill them both, says Gustafson.

Modifier -57 Also Useful in Getting Paid

In addition to modifier -25, you could use modifier
-57, says Cosme. This modifier is for an E/M services visit that results in the decision to perform surgery. Going back to the situation where the patient had a chalazion, lets say the patient needs to have it excised, and the ophthalmologist decides to do it that day. Using the modifier -57 would, in some cases, make it possible to get paid for the office visit and the chalazion excision, says Cosme. Medicare may or may not pay with the -57, she says. The same is true of commercial payers. So you may need to appeal. Remember that there is a high rate of turnaround for people screening these claims, says Cosme. Most do not know what a chalazion is.

Sometimes, says Cosme, the most efficient route is to call the payer and ask what their guidelines are regarding minor surgery. We can appeal until were blue in the face but if its against their guidelines, they wont pay it.

The last option is to reschedule the patient to come in at a later date for the minor surgery. If, for example, the ophthalmologists schedule is full, and there is no time to do an unscheduled chalazion excision that day, you could ask the patient to return. This might be better for the patients schedule, as well.