Ophthalmology and Optometry Coding Alert

Use this quick and easy guide to keep your reimbursement flowing.

Every coder is familiar with the concept of modifiers — those supplemental add-ons that provide more detail than a CPT^® code alone can offer. But what is sometimes fuzzy is the small detail of why you use certain modifiers and how they affect payment.

If you could use a quick primer on the most common eye care modifiers — and how to use them — read on for the scoop.

Know the Payment Modifiers

To understand how a modifier attached to a CPT^® code affects your claims, you need to know the “payment versus pricing” distinction. The two things to consider are:

• If a modifier is not added, will it affect getting paid?
• If a modifier is not added, will it affect the value of the code?

You’ll find the following in your listing of eye care-specific payment modifiers. If you neglect to append these modifiers when they’re justified, it may affect whether the insurer reimburses for the service:

Modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period): The first step to understanding modifier 24 is to get a firm grasp on how global surgical packages work. With a surgical code such as cataract extraction, insurers assign postoperative days, which are zero, 10, or 90 days. Certain E/M services are included in that surgical package and are therefore bundled into the surgical procedure. However, if you see a patient for an E/M visit that’s completely unrelated to the surgery — even if the patient is still in the postsurgical period — you can collect for that service by appending modifier 24 to the E/M code. Without this modifier, your E/M service will most likely be denied due to the payer assuming it should be included in your global package.

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the day of a procedure or other service): You should use modifier 25 when your ophthalmologist’s documentation supports that he performed an E/M service that was significant and separately identifiable from the work included in another service or procedure. To use this modifier, your ophthalmologist not only needs to describe the procedure he performed — he must also document the E/M service provided. You should use modifier 25 only with services that are “significant, separately identifiable” and “above and beyond the usual preoperative and postoperative care associated with the procedure.”

Modifiers E1 Through E4 (E1 for upper left eyelid, E2 for lower left eyelid, E3 for upper right eyelid, and E4 for lower right eyelid): The general rule is to use the E modifiers when a procedure can be performed on any one of the four eyelids. E1-E4 are informational modifiers which do not affect payment, but they do give the payer more clinical information.

Get to Know the Pricing Modifiers 

If you neglect to add one of these modifiers when it’s called for, it may affect the value of the code — meaning, how much you will be reimbursed for it. Pricing modifiers include:

Modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure): These modifiers tell the payer which eye(s) you treated, and in some cases, save you the trouble of having to appeal denials. For instance, if you perform a procedure on the left eye and bill that to the payer without any modifiers, you won’t typically be able to perform the same service on the right eye using the global code, because the payer will assume you are accidentally billing a duplicate service. To ensure the payer knows which specific eye you treated, you can append the LT or RT modifiers, or if you’re reporting a bilateral service, you can append modifier 50. The payment for your procedure could change depending on whether the codes are inherently unilateral or bilateral, so that’s an important consideration when appending these modifiers.

Modifier 22 (Increased procedural service): This modifier can increase your fee if you encounter something during the procedure that makes it inherently more difficult than a standard procedure as described by the CPT^® code. For instance, if a patient has had multiple operations on her left eye, making the surgical field more difficult to address during today’s procedure due to extensive scarring, the ophthalmologist might consider adding modifier 22 to the CPT^® code and explaining why the procedure was more difficult than usual.

Modifiers 52 (Reduced service) and 53 (Discontinued procedure): These modifiers allow you to describe a less extensive service than what’s described by a CPT^® code, and will typically result in your payment being lower than the fee schedule amount. You should append modifier 53 if the physician elects to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient. If, however, the physician electively cancels a procedure, falls short of performing the entire service, or performs a unilateral procedure when the CPT^® code only describes a bilateral one, then 52 is typically the right modifier to use.

Modifier 59 (Distinct procedural service): This modifier indicates that two services which are generally not reported separately are performed on the same day for the same patient, and that extenuating circumstances should allow you to collect for both. You’ll report modifier 59 when there is a different encounter or session, different procedure, different site, or separate incision, excision, injury, lesion, or body part. If another modifier (such as LT, RT, or any other) is more applicable, use that first, since modifier 59 should be considered the modifier of last resort.

Lean on X(EPSU) Instead of 59 When Appropriate

CMS has described modifier 59 as the most widely used modifier, which certainly holds true for most practices, which use it routinely to split codes that have been bundled together by the Correct Coding Initiative (CCI). But CMS notes that many providers misuse it for that purpose. The 59 modifier often overrides the edit in the exact circumstances for which CMS created it in the first place, CMS has said.

To address the problem, CMS created “more precise coding options” with the X(EPSU) modifiers several years ago, which you should use when your payer accepts them. Those codes are:

• XS (Separate structure)
• XP (Separate practitioner)
• XU (Unusual non-overlapping service)

Keep Your Modifiers in Order

When multiple modifiers apply to a procedure, which should you list first?

If you are reporting a code that is bundled into another procedure by CCI, you should first list any modifiers that justify reporting the two procedures together — modifiers like 59 that show that the procedure was necessary and distinct from the other service, say experts.

Next: List any modifiers that affect payment, such as 50 or 52.

Then: List any informational modifiers — such as E1 or E4 — that will not affect the reimbursement for the CPT® code but provide more specific information such as where the eye care physician performed the procedure. Listing informational modifiers before payment modifiers may lead to denials, experts say.