Ophthalmology and Optometry Coding Alert

Question: I heard that if I report mostly CPT 99213s and keep my evaluation and management coding within the middle-of-the-road range, I'll avoid the heat for using modifier 25. Is that true?

Arkansas Subscriber

Answer: No, that's not true.

Reality: The HHS Office of Inspector General and other federal watchdogs are sniffing claims with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), regardless of coding level. Some providers believe that they can slide under the radar by sticking to mid-level E/M codes most of the time, but this practice won't protect you.

Past problems: The OIG issued a tough report on modifier 25 in 2005, and then CMS followed up last May with Transmittal 954 (CR 5025). In that transmittal, CMS emphasized that you can only use modifier 25 when the E/M is different from the usual pre- and postoperative work for a surgical procedure. Your doctor must document why the separate E/M was necessary and exactly what he did, CMS said.

Key: You can't use modifier 25 unless the E/M is a separate and distinct service. Be sure that your physician documented a separate exam if you're going to use modifier 25.

Watch out: According to the Social Security Act, undercoding is as illegal as overcoding, so be sure you're choosing accurate code levels.