Ophthalmology and Optometry Coding Alert

The different-diagnoses stipulation may not apply to E/Ms and minor procedures

If you’re looking for guidance on when it’s appropriate to append modifier 25 to an E/M or eye exam code, take heart -- help from Medicare is coming.
 
After learning from the Office of Inspector General that it had made $538 million in improper payments on incorrect modifier 25 claims in 2002, Medicare is revising The Medicare Claims Processing Manual to clarify when you can -- and cannot -- append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
The OIG study found coding and billing errors in 35 percent of the claims including modifier 25 that it studied. (To learn more about the OIG study, see “OIG Alert: Reserve Modifier 25 for Separate E/M HEM” in the April 2006 Ophthalmology Coding Alert.)
 
Key: In response to the OIG study, CMS released Transmittal 954 on May 19, specifying that modifier 25 is used in cases “when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service.” The transmittal also contains revisions to Chapter 12, Section 30.6.6 (B) of the Claims Processing Manual (“Payment for Evaluation and Management Services Provided During Global Period of Surgery: CPT Modifier 25”).

Append 25 Only for Same-Day Services

The revisions, effective June 1, clarify that:
 
• Coders should only append modifier 25 to E/M services.
 
• Coders should only use modifier 25 when the same ophthalmologist (or same qualified nonphysician practitioner) provides E/M services to the same patient on the same day as another procedure or service.
 
• Different diagnoses are not required for reporting the E/M service and the procedure or other service.
 
• The ophthalmologist or NPP must document both the medically necessary E/M service and the procedure in the patient’s medical record, even though you don’t need to send the documentation with the claim.
 
Don’t miss: Transmittal 954 also reminds coders to append modifier 57 (Decision for surgery) to an E/M service on the day of (or on the day before) a procedure with a 90-day global surgical period, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.
 
Get the facts: To read the transmittal and change request, visit www.cms.hhs.gov/transmittals/downloads/R954CP.pdf. To read an MLN Matters article about the revisions, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM5025.pdf. You can access the entire Medicare Claims Processing Manual (CMS publication 100-04) at www.cms.hhs.gov/Manuals/IOM/list.asp