Ophthalmology and Optometry Coding Alert

Question: When a patient with a foreign body or chalazion comes in as a referral from another doctor, how do I get paid for the exam and the procedure at the same time? I have tried using modifier 25, but I get denials saying the exam is included in the procedure.

Maryland Subscriber

Answer: When an ophthalmologist evaluates a patient for a foreign body in the eye and the evaluation results in the procedure for removal of the foreign body, Medicare and other private payers consider the evaluation of the eye to be included in the preoperative work performed prior to the procedure. It would not be appropriate for you to report both the office visit and the foreign-body removal procedure in this case.

Unless the E/M service was required (other than to examine the eye for a foreign body) and is considered separately identifiable from the preoperative work required for foreign-body removal, you would not be able to also report the E/M service. 

Bottom line: CPT guidelines state that minor-procedure reimbursement includes the office visit as preoperative workup. All procedures, from major eye surgeries to common diagnostic tests, include an "inherent" E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must be "above and beyond" the usual evaluation and management that normally accompanies such a procedure.

The situation changes, however, if your physician see that the patient has another problem during the course of the exam to locate the foreign body, such as cataracts or dry eye syndrome, and decides to do a complete history, exam and medical decision-making following the removal of the foreign body for the other problem.

In this case, separately identifiable documentation and medical necessity for the other problem must be present in the medical record. You could then report the E/M service with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended and linked to the problem diagnosis, while you would link the diagnosis for foreign body to the procedure for the foreign-body removal.

Important: Appending modifier 25 requires a "significant, separately identifiable evaluation and management service."

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, in Clearwater, Fla.