Ophthalmology and Optometry Coding Alert

Submit separate and significant E/M and procedure documentation

CMS is paying more attention to your modifier 25 claims, but that's no reason to avoid using the modifier correctly. Every time you fail to report a legitimate, separately identifiable E/M service, your practice misses out on anywhere from $25 to well over $100.
 
Don't let this happen to you: Here are three tips to help you know when and how to report separate E/M services with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Tip 1: Stress 'Significance'

To gain payment for an E/M service the ophthalmologist provides at the same time as another procedure or service, the E/M must be both significant and separately identifiable.
 
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, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.
 
Example: An ophthalmologist initially sees a patient for a red, painful bump on the right upper lid. He determines the patient has a chalazion and recommends hot packs and an oral antibiotic. He advises the patient that if the chalazion does not resolve, the patient can return for incision and drainage of the chalazion (67800, Excision of chalazion; single).
 
The chalazion does not resolve and the patient returns. The ophthalmologist verifies that the chalazion is still present and takes the patient to the minor-procedure room for the procedure. In this case, the levels of exam, history and medical decision-making (MDM) prior to the procedure on that day are not significant enough to stand on their own as a separate E/M service, says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif.
 
Bottom line: You should consider a brief history and exam prior to a same-day scheduled outpatient procedure as an included component of the procedure itself.

Tip 2: Separate the Documentation

When reporting an appropriate E/M service on the same day as another procedure, physically separate the documentation for the E/M portion of the service from the other procedure(s) or service(s) the ophthalmologist provides.
 
This demonstrates to the payer the E/M service's distinct nature and proves that the E/M service can "stand alone," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
 
Here's how: The ophthalmologist should document the history, exam and MDM in the patient's chart and record the procedure notes on a different sheet attached to the chart. Documentation should support that the patient presented with a complaint that required the ophthalmologist to obtain a current history and perform an examination to determine treatment, the need for further workup and diagnostic testing, or a minor procedure or surgery.

Tip 3: An Unrelated Dx Helps But Isn't Required

When reporting any E/M service, you must link it to a diagnosis that explains the reason the physician performed the service.
 
Important: The E/M service needn't be unrelated to the other service(s) or procedure(s) the physician provides on the same day, Bucknam says. CPT specifically states, "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."
 
But separate diagnoses, when available, do further help to demonstrate the distinct nature of the E/M service -- especially when dealing with payers other than Medicare, Duran says.
 
Example: A patient complains of a red eye and a "scratchy, foreign-body sensation." A slit lamp exam reveals an ingrown lash, which the ophthalmologist removes. Report 67820 (Correction of trichiasis; epilation, by forceps only) and link it with 374.05 (Trichiasis without entropion).
 
Report the E/M service with modifier 25 and link it to 379.91 (Unspecified disorder of eye and adnexa; pain in or around eye).