Ophthalmology and Optometry Coding Alert

Question: A patient was in the office for Botox injections for strabismus. Can we also bill an E/M service with the injection code? Do we need to append modifier -25?

OPC Subscriber

Answer: It is a good idea to hesitate before automatically billing an office visit code with Botox injections.

If it is the patient's first visit, his or her problem is evaluated, a decision is made on how to treat the problem, and the Botox injection is administered, the E/M service is most likely justified. In this case, be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code and also bill the drug administration code.

On the other hand, for repeat Botox treatments when the basic patient-physician interaction is just a few quick questions about the status of the patient followed by the scheduled treatment, you probably won't have the documentation to justify a significant and separate service. If the physician interaction with the patient is integral to the minor procedure, then it is considered preoperative and separately billable.

Answers to You Be the Coder and Reader Questions provided by Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C.; and Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.