Ophthalmology and Optometry Coding Alert

Hint: Make sure to check your documentation and the payer's policy.

You've coded what you're sure is a bulletproof claim for an E/M code and punctal plug insertion. You were sure to append modifier 25 to the E/M code to show that it was separate from the procedure. Your carrier, however, denies payment for the E/M service -- here's our expert game plan.

Should you:

a. look at your documentation?

b. check the insurer's policy?

c. contact the payer's medical director?

d. appeal citing HIPAA and CPT® rules?

Actually, coding experts recommend you do all four.

1. Verify Encounter Meets Modifier 25 Criteria

You should first check that your chart note supports billing the E/M with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Every procedure has a small E/M built into it to represent the preoperative work associated with rendering a procedure. So you must show that you performed a significant, separate service from the procedure or other service.

Medical necessity must exist and be documented to support the performance of an E/M service. This could be the result of an established patient with new symptoms or worsening symptoms for whom a new exam and medical decision-making are necessary.

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 the second procedure. For example, you would report 68761-E2, 68761-51-E4. 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).

Tip: When your chart note's E/M documentation can stand on its own, fight for modifier 25 payment if no carrier policies disallow the particular code combination. You don't have to write the notes on a separate sheet, but visually separating the services or service and procedure will help show you whether the E/M is separately reimbursable.

2. Read the Payer's Rules

Some insurers will not pay for an E/M service in addition to certain procedures or other E/M codes, regardless of your documentation. And if your contract specifies these restrictions, you shouldn't waste time appealing the decision.

Better method: Know your payers' rules. If your contract includes rules that require you to report services differently from CPT® guidelines, you must follow them. But make sure to address these variations when your contract comes up for renewal. Non-Medicare payer bundles vary across the country.

3. Involve Others in Across-the-Board Rejections

But how do you know when a payer's denials have gone from contract-approved denials to inappropriate activity? If an insurer never pays a modifier 25 service, you should find out why, experts advise. Insurers should recognize that an ophthalmologist may sometimes have to provide a separate service.

If a payer consistently rejects modifier 25 claims, raise the ante. Talk to the medical director, and involve your local medical board.

4. Appeal With Regulation, Documentation

When you appeal a modifier 25 decision, remind the insurer of two facts:

1. HIPAA requires that government and third-party payers use ICD-9 and CPT® as the official code set. Because CPT® clearly defines the appropriate use of modifier 25, the insurer must accept the modifier.

2. You have submitted the claim based on documentation that supports using modifier 25. Include a copy of CPT's "Appendix A -- Modifiers" description of modifier 25 along with a standard form letter.