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Ophthalmology and Optometry Coding Alert

Punctal Plugs:

Fight Back Punctal Plug Denials With These 4 Steps

Published on Wed Sep 05, 2012

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 CriteriaYou 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 [...]
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