Ophthalmology and Optometry Coding Alert

When the diagnosis is the same or similar for an office visit and minor surgery, commercial insurance plans may deny the claim. When performing an audit, Medicare will make sure that the office visit is significant and separately identifiable from the minor surgery, whether the procedure is starred or not.
 
CPT states that starred procedures are separate procedures. Some payers may interpret this to include the E/M services unless special circumstances exist, explains Ann Rose, president of Rose and Associates, an ophthalmology coding and compliance consultancy based in Duncanville, Texas. Denote special circumstances by appending modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code (99xxx), indicating a service was performed that is separate and beyond what the preoperative procedure required.
 
Keep two things in mind when using modifier -25:
 
1. Documentation of the minor procedure is key; the elements of the exam that constitute the E/M service are a matter of local medical review policy.
 
2. Link the diagnosis code for the sign or symptom that brought the patient to the office to the E/M service and the diagnosis code for the condition the physician found and treated to the minor procedure.

Four common procedures foreign body removal, chalazion excision, epilation for trichiasis, and punctal plug placement sometimes require additional up-front work by the ophthalmologist, as represented by a billable office visit and modifier -25.

Foreign Body Removal

One of the trickiest examples of using modifier -25 is foreign body removal (65205-65222, 67938, 68530). Consider the patient's chief complaint and the nature of the exam before deciding whether to check off "office visit" on the superbill, Rose recommends.
 
Most ophthalmologists perform an exam, identify the foreign body and attempt to remove it. "In the case of foreign body removal, the standard of physician practice is to examine the eye and remove the foreign body on the same day," says Raequell Duran, president of Practice Solutions, an ophthalmology reimbursement and coding consultancy based in Santa Barbara, Calif. "The issue becomes one of documentation." Document the history, exam and decision-making first and then do a dated entry for the procedure.
 
Many ophthalmologists make the documentation mistake of describing the foreign body removal in the slit lamp portion of the examination, which makes the procedure appear to be the same as the visit, Duran says. That documentation makes it virtually impossible to bill the procedure and the E/M service, even though both codes are otherwise justified.
 
Code procedure and office visit with modifier -25: A patient complains of tearing, pain and redness in the eye. The ophthalmologist performs a complete examination to determine the cause and finds it is a corneal foreign body. The physician removes the foreign body, billing 65222* (removal of foreign body, external eye; corneal, with slit lamp) and links it with 930.0 (foreign body on external eye; corneal foreign body). The physician bills the E/M service with modifier -25 appended and links it with 379.91 (unspecified disorder of eye and adnexa; pain in or around eye).
 
Code procedure only: This would rarely occur with foreign body removal. The physician would not remove the foreign body without examining the eye.

Chalazion

Code procedure and office visit with modifier -25: The patient presents with a red, sore bump. The ophthalmologist documents the history of present illness and the complaint, examines the patient and documents his or her findings including an impression and plan for the presenting problem. The procedure is documented separately from the examination. Use 67800 (excision of chalazion; single) and append modifier -25 to the E/M service. This is not a starred procedure but modifier -25 is still recommended to indicate a separate service.
 
Code procedure alone: A patient returns for a chalazion that was not resolved with medical treatment and requests surgical drainage. The visit to the office is scheduled as a chalazion incision and drainage. The assistant puts the chalazion tray in the room for the doctor, and the doctor does nothing else beyond the procedure. Code 67800 alone. No separate office visit should be billed, because nothing separate and identifiable from the surgery was done. Any physician work aside from the intraoperative portion of the service is preoperative.

Epilation

Code procedure and office visit with modifier -25: A patient complains of a red eye and a "scratchy, foreign body sensation." The physician does a slit lamp exam and sees that there is a lash growing in towards the eye causing irritation. The physician removes the lash. Bill 67820* (correction of trichiasis; epilation, by forceps only) and link it with 374.05 (other disorders of eyelids; entropion and trichiasis of eyelid; trichiasis without entropion). Bill the E/M service with modifier -25 and link it to 379.91.
 
The Medicare intermediary should be able to process payment for the office visit and the minor procedure when billed with the same diagnosis code, Duran says. But using two different diagnosis codes, while not required, may get your claim paid without requiring documentation of a significant and separately identifiable office visit.
 
Code procedure alone: An established patient with chronic trichiasis problems comes in and reports that he has another ingrown eyelash. (Patients who have had this recurring condition recognize it.) The ophthalmologist looks with the slit lamp to locate only the aberrant lash, agrees, and removes it. Bill 67820* with 374.05, and no office visit.

Punctal Plugs

Code procedure and office visit with modifier -25: A patient reports dry, itchy or sandy eyes and pain. The ophthalmologist performs a complete eye examination to rule out other causes but determines that the patient has dry eyes. The ophthalmologist places collagen punctal plugs in the two lower puncta to see if this resolves the problem. Bill 68761 (closure of the lacrimal punctum; by plug, each) on two lines with -E2 (lower left, eyelid) and -E4 (lower right, eyelid) appended to denote the lids. Link 375.15 (other disorders of lacrimal gland; tear film insufficiency, unspecified) to the punctal plug closure codes. Also bill an E/M service with modifier -25 and 379.91. 
 
Code procedure alone: The same patient returns for a follow-up visit in three weeks and reports great improvement following the placement of the punctal plugs. The ophthalmologist places permanent, silicone punctal plugs in the two lower puncta. Use 68761-E2 and 68761-E4 for the procedure and 375.15 for the dry eye condition. Do not bill an E/M service without a separate exam.

Modifier -25

Modifier -25 requires clear documentation that a significant and separately identifiable office visit was rendered, Duran says. "This can be done very effectively by creating separate documentation for the minor procedure." Documentation is best done on two pages:
 
Page 1 Documentation of the visit: At a minimum, documentation of the visit should incorporate the patient's chief complaint, history of present illness, review of the system of complaint and any related system examination and medical decision-making documenting the physician's impression and treatment plan.
 
Page 2 Documentation of the minor procedure: Documentation of the minor procedure should include the patient's name, date, type of procedure and instrumentation, medications or anesthetics used. "Too often, minor procedures performed at the slit lamp are documented by writing a brief note, such as 'foreign body removed,'" Duran says. "When documented within the examination, the minor procedure becomes the main service and the office visit part of the preoperative service integral to the procedure."

Private Payers

Many private payers require separate diagnoses for coverage. Some require that the diagnosis for the visit not be explained by the diagnosis for the procedure. For example, the diagnosis code for red eyes, 379.93 (unspecified disorder of eye and adnexa; redness or discharge of eye), would be explained by the diagnosis code for trichiasis (374.05). These payers want diagnosis codes that are unrelated to each other, like nuclear sclerotic cataracts (366.16) and dry eye syndrome (375.15). 
 
No matter how good your documentation, private payers may not pay for both services. Medicare will respect modifier -25 if the documentation reflects distinct services; payers such as Blue Shield often bundle the office visit with the minor procedure, Duran says.
 
Although physicians still await clarification from CMS on using modifier -25, the current definition does not require a different diagnosis. But Medicare requires documentation of separate services, and some private payers require not only different, but unrelated, diagnoses. Ophthalmologists performing minor procedures such as foreign body removal, epilation and punctal plug placement must respect the documentation requirements for coding an E/M service in addition to these procedures to emerge unscathed from an audit. The E/M service should reflect a history, examination, assessment and plan that should indicate the intention to perform the minor procedure. There should be a separate, dated entry for the minor procedure that states what was done, how the patient tolerated it and what instructions were given to the patient for postoperative care.
 
Note: Patients should sign consent forms for minor procedures performed in the office. Many auditors look for this documentation.