Modifiers -25 and -57:
Get Paid for Minor Surgical Procedures and Office Visits
Published on Fri Oct 01, 1999
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 [...]
