Ophthalmology and Optometry Coding Alert

Question: How should I code the work when a patient came in for a complete eye exam, and the ophthalmologist finds trichiasis and epilates the lashes? Previously, I had reported 92014 (for the comprehensive exam) with modifier -25 along with 67820 (for the epilation), but the carrier denied the claim. But when I filed the two codes without modifying 92014, they paid the claim. Now Medicare is asking for all those 92014 payments back. What should I do?

North Carolina Subscriber

Answer: To meet the requirements for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), you must prove that 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits) was significant and separate from 67820 (Correction of trichiasis; epilation, by forceps only).

The key is why the patient is being seen. Your ophthalmologist saw this patient for a "complete eye exam," and that's not a reason for Medicare to pay for an office visit. If he's seeing the patient for a yearly follow-up of a known, chronic condition (such as cataracts), then that is the reason for the visit. Link that diagnosis to 92014 and 374.05 (Other disorders of eyelids; trichiasis without entropion), or 374.00-374.04 (Entropion and trichiasis of eyelid) to 67820.

Don't miss: Be sure you are meeting the requirement of your local carrier for billing 92014. Most carriers have their own policy for the general ophthalmological services, defining what must be documented for comprehensive and intermediate levels of the eye exam codes.