Ophthalmology and Optometry Coding Alert

If you bill claims to Independence Blue Cross Blue Shield, watch out for reductions.

Eye care practices that use modifier 25 may see their odds of collecting full pay for this frequently-reported modifier dropping dramatically. That's the word from Pennsylvania's Independence Blue Cross Blue Shield, which is making drastic reimbursement changes to the modifier.

Here's why: Effective Aug. 1, Independence will reimburse claims appended with 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) "at 50 percent of the applicable fee schedule amount" in the following circumstances, the payer said in a May 1 notification:

• When the E/M service is submitted on the same date of service, by the same provider, as a minor procedure
• When a problem-focused E/M service is submitted on the same date of service, by the same provider, with a preventive E/M

In addition, Independence's notification indicates that when you're using modifier 25, "documentation for the additional E/M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E/M service." Therefore, it appears that this payer will no longer allow you to document both the E/M and the procedure in the same sentence or paragraph of the note.

Pay Cuts Could Be Major

Seeing your pay fall by 50 percent for E/M services with modifier 25 appended could be a drastic change for eye care practices. For example, when you report 99205 (Office or other outpatient visit for the evaluation and management of a new patient...), you normally collect about $210, based on the 2017 Medicare Physician Fee Schedule values. However, under the new Independence Blue Cross rules, that number will fall to just $105. Say you report 99205-25 twice a day at your practice - you've now lost $1,050 a week, or almost $55,000 annually, from Independence Blue Cross Blue Shield.

"This policy is absurd," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO,  AAPC Fellow and vice president at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. Although the policy is not a broad CMS directive, it could begin to infiltrate other payers if practices affected by it don't act quickly.

"This will be problematic especially since they are including initial services in the list of applicable E/Ms," says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. "Now, if you decide to intervene with the patient at the conclusion of the initial evaluation, you will be penalized and not rewarded for all of your hard work and time."

Check This Example for Clarity

Consider the following example to illustrate how the Independence policy will impact practices.

Example: A patient presents with a red, sore bump on the eyelid, and after performing an E/M service, the doctor determines it is a chalazion, for which he performs an incision and drainage of the chalazion during the same visit. In this case, the doctor would have to accept the 50 percent payment reduction from the E/M that day, or else would have to ask the patient to return on another day to perform the chalazion excision so he could get full pay for both the E/M service and the excision (which would be billed with a code from the 67800-67808 series).

Consider this advice: Contact your state medical society to see if this policy represents such a radical reinterpretation of contract terms that is not a legally allowable unilateral amendment without the payer getting permission from the state's department of insurance or other regulatory body. Some states have such regulations.