Ophthalmology and Optometry Coding Alert

HHS will scrutinize your unbundling next year - are you ready?

How confident are you in your claims with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)? Be warned: Your coding had better be bulletproof if you don't want to attract unwanted attention from the HHS Office of Inspector General next year.

According to the OIG's 2005 Work Plan, which was just released, the office will continue its probe into claims submitted with modifier -25 appended to bill for E/M services on the same day as procedures.

Improper use of modifier -25 has risen in the past decade, and it's made regulators take notice. In 2003, the Department of Health and Human Services instructed OIG to start paying extra attention to modifier -25 claims in an attempt to catch people who were abusing the modifier.

The most difficult modifier -25 issue is ensuring that the E/M service is actually separate from the other procedure, not just a component of the procedure, says Lisa Center, CPC, of Freeman Health System in Joplin. Mo.

"Each service - the E/M and the procedure - needs to be able to stand alone [on the claim]. That is the point of the -25 modifier, to show it is a separately identifiable service," Center says.

While a separate diagnosis code isn't necessary to report the E/M code, "Oftentimes it is helpful to show that it is separate from the procedure," says Mark Gardinier, insurance coordinator for Corneal Consultants of Colorado in Littleton.

Example: A patient reports dry, itchy eyes and generalized pain. The ophthalmologist performs a complete eye exam - separate from the procedure - to rule out other causes, and he diagnoses dry eyes. He places collagen punctal plugs in the two lower puncta to see if this resolves the problem.

Report 68761 (Closure of the lacrimal punctum; by plug, each) on two lines and append -E2 (Lower left, eyelid) and -E4 (Lower right, eyelid), plus modifier -51 (Multiple procedures), to denote the lids. Link 375.15 (Other disorders of lacrimal gland; tear film insufficiency, unspecified) to the punctal plug closure codes. Also report the appropriate-level E/M service with modifier -25 and link it to 379.91 (Pain in or around eye).

Break Bundles - Not Regulations - With Modifier -59

Also continuing next year is OIG's investigation of claims using modifiers to override National Correct Coding Initiative edits. The OIG has been looking into this issue since 2002. This continued focus may cause problems for practices in the habit of submitting claims with modifier -59 (Distinct procedural service) to break an NCCI bundle.

Append modifier -59 "if you really feel that you are doing the distinct work of both procedures," Gardinier says. But because -59 is the "modifier of last resort," you should never use it if another modifier will tell the story, according to CPT guidelines.

Example: A patient presents for possible ptosis repair. To establish medical necessity, the ophthalmologist performs two sets of visual fields - the second one with the excess skin taped aside to represent the patient's potential improved field of vision. You could report code 92081 (Visual field examination, unilateral or bilateral, with interpretation and report; limited examination [e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent]) twice, appending modifier -76 (Repeat procedure by same physician) to the second line.

Warning: Some carriers' LMRPs or LCDs may not permit you to bill two sets of visual fields this way. Check with your carrier for its preferred method of billing.

Note: To view the OIG's Work Plan online, visit http://oig.hhs.gov/publications/workplan.html#1.