Ophthalmology and Optometry Coding Alert

Often an ophthalmologist sees a patient and decides a procedure needs to be performed the same day. How does the ophthalmologist get paid for the office visit as well as the procedure? When this procedure is minor, such as chalazion excision (67800, 67801, 67805) or epilation to correct trichiasis (67820*), the key is to use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit.
Some practices think they need to charge modifier -57 (decision for surgery). However, modifier -57 is only for major surgery. If, for example, the physician needs to perform a retinal detachment repair (major procedure) the same day, that would definitely call for a modifier -57 on the office visit, and not a modifier -25.

Ophthalmology coders who get confused about whether to use modifier -25 or modifier -57 when a decision is made to perform minor surgery on the same day should remember that anything with a 90-day global gets a modifier -57; minor procedures get a modifier -25, explains Catherine Brink, CMM, CPC, president of Healthcare Resource Management, a consulting firm in Spring Lake, N.J. Use modifier -25 when the procedure has a global of zero to 10 days. Modifier -57, notes Brink, says that the ophthalmologist needed to do a separate evaluation and management (E/M) service to decide that major surgery was necessary, whereas modifier -25 says that a separate and identifiable service was performed that is distinct from a minor procedure performed the same day.

One tipoff is if the procedure is starred in CPT. Epilation (67820*) is a starred procedure, for example. This tells you that you can definitely bill for an office visit as well. Thats because the ophthalmologist needs to decide how to handle the patients uncomfortable sensation and make sure that there are no ulcerations or other problems related to the lash irritation. More than just the procedure is required for reimbursement; the doctors medical decision-making is necessary as well.

There is a change in CPT 2000 that requires the use of modifier -25 on office visits being billed with starred procedures, but not all minor procedures identified in the Medicare program are starred in the CPT book. For example, chalazion excision is not. Nevertheless, if you want to get paid for an office visit as well as the excision, you should use a modifier -25 on the office visit to make sure its clear that there is a separately identifiable procedure involved. You can look at your Medicare fee schedule to identify the surgical codes that have zero to 10 days of follow-up care.

But you will not always be able to bill an office visit as well as the procedure. Remember, modifier -25 is for a separately identifiable procedure or service. For example, if a glaucoma patient came in for a pressure check and at the same time complained about a chalazion, you could bill for the office visit with the diagnosis code of glaucoma, and then for the chalazion excision with the chalazion diagnosis code, explains Marlene Monroe, insurance manager for Eye Care Centers, LLC, a seven-provider practice in Harriman, Tenn. It helps to have two different diagnoses, says Monroe, although CPT doesnt require it for the use of modifier -25. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided, CPT states in the descriptor for modifier -25. As such, different diagnoses are not required for reporting of the E/M services on the same date.

Another example is if a patient comes in complaining of vision problems and has a cataract in the left eye, but also has trichiasis (374.05) that requires epilation in the right. Or the two problems could even be in the same eye. They are unrelated, however, and there is no way the epilation would cover the cataract, so you should bill both the office visit with a modifier -25 and the epilation.

Another consideration in deciding whether to bill an office visit is whether the patient has been seen recently for the problem. Lets say the patient has a chalazion that was seen 10 days ago, and the ophthalmologist said to use hot packs and an antibiotic ointment to see whether it would resolve without surgical intervention. It didnt resolve, so the patient returned to have it excised, saying it was still swollen. At this visit, all that is done is the chalazion excision. You wouldnt be able to charge an office visit in this case, says Brink. In order to charge for a follow-up E/M, there must be a separate, identifiable service.