Ophthalmology and Optometry Coding Alert

Question: When a patient with a foreign body or chalazion comes in as a referral from another doctor, how do I get paid for the exam and the procedure at the same time? I have tried using modifier 25, but I get denials saying the exam is included in the procedure.

Maryland Subscriber

Answer: When an ophthalmologist evaluates a patient for a foreign body in the eye and the evaluation results in the procedure for removal of the foreign body, Medicare and other private payers may consider the evaluation of the eye to be included in the preoperative work performed prior to the procedure. Unless your documentation demonstrates a separately identifiable E/M services that’s completely separate from the procedure, it would not be appropriate for you to report both the office visit and the foreign-body removal procedure in this case.

Bottom line: CPT^® guidelines state that minor-procedure reimbursement includes the office visit as preoperative workup. All procedures, from major eye surgeries to common diagnostic tests, include an “inherent” E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must be above and beyond the usual evaluation and management that normally accompanies such a procedure.

Remember: Appending 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) requires a “significant, separately identifiable evaluation and management service.”