Ophthalmology and Optometry Coding Alert

Question: We sometimes get denials that appear to be related to bundling issues but I can't find the two-code pair in the CCI edits. How can I find out which is the column 2 code so that I can put the modifier on the correct code?

Answer: If you can't find the codes listed in the Correct Coding Initiative (CCI) edit tables, then they're not bundled under that system. Make sure you check both the mutually exclusive and nonmutually exclusive edit tables and you are looking at the CCI Edit tables specific to the date of service of the claim. CCI Edits are updated every three months and need to be referenced accordingly.

If your code pair is not bundled under CCI, then you would not need a CCI modifier such as 59 (Distinct procedural service), to override the edit pair.

Example: The ophthalmologist saw a glaucoma patient and performed a gonioscopy. The ophthalmologist also took slit lamp photographs to document an iris nevus during the same session. You see that codes 92285 (External ocular photography with interpretation and report for documentation of medical progress [e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography]) and 92020 (Gonioscopy [separate procedure]) are linked in a CCI bundle. However, you can report the two services separately using modifier 59 and separate diagnosis codes in certain circumstances. Because the ophthalmologist performed the gonioscopy and the slit lamp photos for different reasons, you can report both procedures:

• Link the appropriate iris nevus diagnosis code (224.8, Benign neoplasm of eye; other specified parts of eye) to 92285 for the photos.
• Attach modifier 59 and the appropriate glaucoma diagnosis code (365.x) to 92020 () to represent the gonioscopy. You should also document the physician's findings and the condition's status in the interpretation and report for the test.

Why? The modifier tells the insurance carrier that the iris nevus and gonioscopy were separate procedures, not components of one another. Because 92020 appears in column 2 of the CCI edits, append the modifier to that code and not 92285, which is the column 1 code.

Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won't need a CCI modifier to override the edit, you might need a payment modifier.

You can find Medicare's other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if a modifier such as 50 (Bilateral procedure), etc. applies. This info is also in Codify's fee schedule information (https://www.aapc.com/codify/medicare-fee-schedules.aspx).