Ophthalmology and Optometry Coding Alert

Question: When the ophthalmologist does a comprehensive exam (92004) and decides to insert punctal plugs on the same day, do I need to append modifier 25 to 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 on the same day of the procedure or other service). Some payers may pay for the "eye codes" without modifier 25 when reported with a procedure or diagnostic service.

You should first check that your chart note supports billing the eye code with modifier 25. You have to prove that the eye code 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 evaluation and management services already built into it.

Watch for: You may determine that another coding option, such as an E/M code (99201-99215), suits a particular service better than an eye code. Always report the code that is 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 or eye code if medical necessity supports the new evaluation and management services.