Ophthalmology and Optometry Coding Alert

Although every eye care physician reports ophthalmological services and E/M codes regularly, sometimes the coding doesn’t stop at CPT^® and HCPCS Level II codes. In many cases, you must append modifiers to these codes, which can prompt confusion since the utility of several modifiers appear to be somewhat similar.

Part B representatives aimed to clear up such confusion during the April 23 webinar “Evaluation and Management Modifiers,” presented by Part B payer NGS Medicare. We’ve rounded up a few of the guidelines most applicable to ophthalmology practices, and we’re sharing them to ensure that you bill appropriately.

1. Know What the Modifiers Do

“A modifier is a two-position alpha or numeric code added to the end of a CPT^® or HCPCS code to clarify the service being billed,” said NGS’ Michele Poulos during the call. “A modifier provides the physician with the means to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition of the code.” Modifiers also help eliminate the appearance of duplication or unbundling, she added.

Keep in mind: The documentation must support the use of the modifier, and not all modifiers are recognized by Medicare.

2. Remember the 2 Types of Modifiers

The modifiers fall into two main categories, Poulos notes. Pricing modifiers impact the payment amounts you’ll receive and should always be placed in the first modifier field. Informational modifiers, however, provide additional information regarding the service being performed, but do not affect the payment amount, and should be used in the second, third, or fourth field if a pricing modifier is also being used.

“The multicarrier systems used for claims processing allows up to four modifiers per claim line,” she added.

3. Use Modifier 24 for Unrelated E/Ms During Global

You’ll use modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) “when an unrelated E/M service or eye exam is performed by the same physician during the postoperative period of a procedure with a 10- or 90-day global period,” Poulos said.

You should never use modifier 24 for services rendered on the same day as the surgical procedure — in those cases, you’ll typically use 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) instead, Poulos said. In addition, you’ll never use modifier 24 for a complication of the original procedure, you can’t append it to the surgical procedure code, and it doesn’t apply to the removal of sutures or other wound treatment, since these are part of the surgical service. “These are all common denial reasons for this modifier,” she noted.

Documentation must support the fact that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter, Poulos added.

4. Modifier 25 Applies to E/M With Minor Procedure

“Modifier 25 may be appended to E/M services that are reported with minor surgical procedures with global periods of 0 or 10 days, or procedures not covered by global surgery rules,” Poulos said. Remember that the E/M service performed with the procedure must be both significant and separately identifiable to justify the use of modifier 25. Minor surgeries and procedures include pre-procedure, intra-procedure, and post-procedure work, so you should never report a separate E/M service for this work, she said.

“Remember that the fees for E/M services are already built into the surgical procedure, so you should be very cautious when you decide to use this modifier, and your physician should make that decision that in their professional opinion, the E/M service they’re providing is above and beyond the E/M service already associated with the procedure.”