Ophthalmology and Optometry Coding Alert

Only reporting one code? Hold the modifiers!

In a recent study, the Office of Inspector General (OIG) cast a spotlight on your use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), and the results weren't pretty. The OIG found a 35 percent error rate for modifier 25--and $538 million in improper payments--in its sample of claims from 2003.

The OIG is encouraging CMS' Part B carriers and Recovery Audit Contractors to scrutinize your claims that use this modifier--and you can expect to see a lot more pre- and post-payment audits.

Modifier 25's descriptor of a significant, separately identifiable E/M service isn't at the root of most of the claim problems. Only 2 percent of improperly coded modifier 25 claims involved E/M services that weren't significant and separately identifiable, according to the OIG.

Reality: Some 27 percent of modifier 25 claims were missing documentation of the E/M service or the procedure performed. For example, in one case, documentation showed that the provider performed a procedure but offered no information about a separate E/M service (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...). "Another provider documented the E/M service provided to a beneficiary but did not document that the procedures were performed," says the OIG in its study, titled "Use of Modifier 25."

The OIG wants CMS to educate providers and reinforce the requirement that you should only use modifier 25 with services that are "significant, separately identifiable" and "above and beyond the usual preoperative and postoperative care associated with the procedure."

Example 1: A patient has a red, sore bump, 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 379.92 (Unspecified disorder of eye and adnexa; swelling or mass of eye) linked to the visit code. Bill the procedure code (67800-67805) with 373.2 (Inflammation of eyelids; chalazion) linked to it.

Example 2: A patient complains of a foreign-body sensation in one eye. The physician finds trichiasis and treats with epilation (67820, Correction of trichiasis; epilation, by forceps only).

Append modifier 25 to the office visit with 379.91 (Unspecified disorder of eye and adnexa; pain in or around eye) linked to the visit code, and link 67820 to 374.05 (Other disorders of eyelids; trichiasis without entropion) or 374.00-374.04 for one of the trichiasis-with-entropion codes.

Best bet: When using modifier 25, you should remember the maxim "If you don't have a HEM, you can't bill an E/M," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute in Absecon, N.J.

Here, "HEM" stands for "history, exam and medical decision-making." All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM, Jandroep says.

Scratch Modifier 25 From Single-Procedure Claims

Most coders understand that modifier 25 submissions require a minimum of two procedure codes--the modifier describes an E/M service that occurs on the same day as another procedure. But that lesson escaped coders in 9 percent of the OIG's reviewed cases.

Modifier 25 appeared in 2.6 million claims even though the E/M visit was the only service the physician reported that day--meaning the modifier was unnecessary. "Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service," says Kent J. Moore, manager of Health Care Financing and Delivery Systems in Leawood, Kan. When submitting claims consisting solely of an E/M code, make sure you don't include modifier 25, he says.

Find out more: To download a copy of the study, visit http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.