Ophthalmology and Optometry Coding Alert

At issue: Whether to report intravitreal injections with E/M services.

Some eye care practices are so accustomed to tacking modifier 25 onto their E/M services that they don’t always stop to check whether their documentation supports its use. But appending it incorrectly can lead to a world of trouble, as one New York ophthalmologist recently discovered.

The case: The ophthalmology practice in the case used modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) even when his documentation did not demonstrate a significant, separately identifiable E/M visit. “For example, in certain instances, the practice performed and billed for ophthalmology procedures known as intravitreal injections (i.e. injections into the eye) and then billed modifier 25 for additional evaluation and management services to the same patients, although the medical records lacked sufficient documentation to support billing for care beyond the injection procedure itself,” The Department of Justice said in a June 13 news release.

Important: “Modifier 25 should be used only when the evaluation and management service is above and beyond the usual pre-and-post operative work of a procedure and the need for the additional service is supported by the medical record,” the DOJ added. Since the ophthalmology practice in the case did not meet these criteria, it was alleged to have collected more compensation than it deserved and had to pay the government $113,722.10to resolve the allegations.

The whistleblower who told the government about the practice’s billing habits will collect $19,332.76 of the settlement proceeds, even though the practice told the government about its improper modifier 25 use before it knew about the lawsuit.

“When an organization catches an error in their Medicaid billing and self-reports, it prevents hardworking New York taxpayers from having to absorb the cost,” said New York Attorney General Eric T. Schneiderman in the news release. “Reimbursing Medicaid for false claims is vital to the integrity of the program, and we will continue working to ensure that all providers repay what is owed.”

The takeaway: To avoid the fate that this practice endured, brush up on three key features of modifier 25 use below.

Tip 1: Read the Documentation

This step may seem like a no-brainer, but it may be surprising to hear that many practices tell the Coding Alert that their coders are too busy to review documentation, so when the doctor marks certain codes on his EHR or superbill, the coders simply bill those codes.

Unfortunately, not all physicians are aware of the intricacies of modifier 25 billing rules, so even though they may think they performed and documented what was required of both an E/M service and a procedure, they aren’t always right.

Therefore, you should audit charts that contain modifier 25 claims and check the documentation to ensure that they meet the modifier 25 rules. If you see one of the physicians not meeting the requirements, you can pull the rest of his charts to determine whether it’s a widespread issue, and then sit down with him to explain the regulations.

Here’s how: “Practices should bring in an expert auditor to review their coding utilization profile, including appendage of high risk modifiers, which include modifiers 24, 25, 59, 78 and 79,” says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida.

“The number of encounters to be reviewed depends on the utilization of these modifiers, but should be no less than 15 to 20 encounters per modifier,” Mac says. “If problems are seen, it is time to address a bigger sample and possibly even consider a self-disclosure. I recommend performing reviews such as this when there is already a suspected concern to be done under an ‘Attorney-Client, Privileged and Confidential’ agreement,” Mac advises.

Tip 2: Get out Your Red Pen

When you pull the sample records, you’ll review the documentation of the encounter for which modifier 25 was billed and cross out anything that is directly related to the procedure performed. Look then at the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary.

Remember:  You can only consider reporting modifier 25 when coding an E/M service or eye exam code with the procedure. If the procedures you’re reporting don’t fall under E/M services, it’s possible the encounter qualifies for another modifier instead.

Example: A patient has a red, sore bump on the right upper eyelid, and the ophthalmologist — after a history and examination— determines it is a chalazion. The ophthalmologist performs an incision and drainage/curettage of the chalazion during the visit, so you should append modifier 25 to the office visit with H57.8 (Other specified disorders of eye and adnexa) linked to the visit code. Bill the procedure code (67800-67805) with H00.11 (Chalazion, right upper eyelid) linked to it.

Tip 3: Unrelated ICD-10 Codes Help — But Aren’t Required

When reporting any E/M service, you must link it to a diagnosis that explains the reason the physician performed the service.

Important: CPT^® specifically states, “The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.”

But separate diagnoses, when available, do further help to demonstrate the distinct nature of the E/M service, especially when dealing with payers.

Example:  A patient complains of a red eye and a “scratchy, foreign-body sensation.” A slit lamp exam reveals an ingrown lash of the left upper eyelid, which the ophthalmologist removes. Report 67820 (Correction of trichiasis; epilation, by forceps only) and link it with H02.054 (Trichiasis without entropion left upper eyelid). Report the E/M service with modifier 25 and link it to H57.12 (Ocular pain, left eye).

“However, the E/M must be medically necessary,” Mac says. “Many payers do not feel that patients presenting with these types of symptoms should be billed with an E/M. The work of a focused exam to determine what is causing the ‘foreign body sensation’ is felt to be part of the procedure and therefore the E/M is not separately payable. However, if you discovered during the exam that the patient had another problem such as dry eye syndrome, that would certainly justify a complete E/M workup with history, exam and MDM separate from the removal of the eyelash.”

Resource: To read more about the case involving the ophthalmologist’s six-figure payment, visit https://www.justice.gov/usao-ndny/pr/university-rochester-pay-more-100000-resolve-false-claims-act-lawsuit.