Ophthalmology and Optometry Coding Alert

Question: A patient presents with an eyelid lesion, which the ophthalmologist excised. Aetna denied the claim I submitted with codes 11440, 99212-57. Did I use modifier 57 correctly?


New Jersey Subscriber

Answer: Modifier 57 (Decision for surgery) is for the decision to perform major surgery. For a minor procedure such as 11440, the correct modifier to append to the E/M service is 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Medicare's Physician Fee Schedule Database denotes 11440 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) as a minor procedure, meaning one that contains 10 global days.

Therefore, you should attach modifier 25, not modifier 57, to the office visit code. This coding advice is consistent with Medicare guidelines that private payers may adopt. The ophthalmololgist's documentation should support the E/M service as significant and separately identifiable from the same-day lesion excision.

Tip: Use modifier 57 when a physician performs an E/M service that results in the decision to perform a same-day procedure with a 90-day global period. For instance, during a consultation, an ophthalmologist determines he needs to repair a detached retina that day. He performs 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling and/or removal of lens by same technique).

Because the detached retina repair is a major procedure, you should append modifier 57 to the E/M service code (99241-99245 for consultations), and documentation should specifically note that the E/M service resulted in the decision for surgery.