Ophthalmology and Optometry Coding Alert

Question: When my optometrist does a comprehensive exam (92004) and decides to insert punctal plugs on the same day, do I need the 25 modifier on the exam?

Texas Subscriber

Answer: If you plan to report 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits) separately, then yes, you would need to append 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).

Not every payer requires the modifier with the eye code when billing it in addition to a procedural service. You may need to check with your specific payers.

If submitting the procedure with an E/M code, you should first check that your chart note supports billing the E/M with modifier 25. You have to prove that the E/M was a significant, separate service from the punctal plug insertion (68761, Closure of the lacrimal punctum; by plug, each) because every procedure has a small amount of E/M service already built into it.

Tip: Ask yourself whether the E/M documentation – which should also indicate medical necessity for the E/M and subsequent procedure – would stand alone for payment if you hadn’t inserted the punctal plugs.

Watch for: You may determine that another coding option, such as ophthalmic exam codes 92002-92014, suits a particular service better than an E/M code. Always report the code that is most appropriate for your service.

Most important: There is a 10-day global period for punctal plug insertions. If the patient reports improvement later, and returns within 10 days to have permanent plugs placed, you may only bill for the insertion – not a separate office visit – because the plug insertion is the only reason for that visit.

However, if the patient returns after 10 days, you can bill an E/M code only if it is necessary for your provider to perform another E/M service.