Ophthalmology and Optometry Coding Alert

Question: When treating a new or established patient and then deciding to do a PRP laser (67228) the same day, do we need to append modifier 57 (Decision for surgery) to 67228 (Treatment of extensive or progressive retinopathy [eg, diabetic retinopathy], photocoagulation) now that it has a global period assigned to it?

Answer: No, modifier 57 is not the best choice, since that modifier only applies to procedures with 90-day global periods. Instead, you should 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) to the E/M code when deciding to do the procedure the same day as the E/M, because 67228 has a ten-day global period.

Remember that your documentation for the E/M should be very thorough and not just “Patient required PRP laser.” In fact, your E/M should be robust enough that you can remove it completely from the procedure notes for the PRP and both services will have enough documentation to stand on their own.

As an aside, even services that have “000” global days assigned to them often require a modifier to report the E/M the same day as the procedure. The 000 classification means the procedure adheres to bundling rules only on the date of the service. Most payers will therefore bundle all services that you perform on the procedure date into codes with this 000 global period.