Ophthalmology and Optometry Coding Alert

Correctly determining when modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) is a justified appendage to an office visit - E/M codes, eye codes and consultations - can be the difference between a denied and a paid minor procedure claim.

Suppose a patient comes in for a glaucoma check and that's her main complaint. But during the check she also complains that she has an irritation on the other eye. It could be that she has trichiasis, which means she needs lash epilation. In this case, both the glaucoma E/M service and the epilation minor procedure would have to be coded, says Marcia Porter, CPC, CHCC, an ophthalmology coder in Charleston, SC. "We need -25 for the E/M code, which corresponds to the glaucoma diagnosis" to be paid for both services when performed on the same day during the same visit.

Another case that requires -25 is if a patient presents with localized swelling and erythema underneath her left eye that has no discharge but has lasted for one week, which the physician initially diagnoses as 379.92 (Unspecified disorder of eye and adnexa; swelling or mass of eye). After the ophthalmologist performs a complete E/M on the patient and diagnoses the inflammation as a chalazion, he performs an incision and drainage/curettage of the chalazion.

If the coder recognizes the office visit and initial diagnosis as separately identifiable, the services rendered the patient will be billed an E/M code (99201-99215) or an eye code (92002-92014) with modifier -25 and the minor procedure code (67800-67805). Link the E/M service to the initial diagnosis of 379.92 and the chalazion procedure code to the post-E/M service diagnosis, 373.2 (Inflammation of eyelids; chalazion). If the coder had not appended modifier -25 to the office visit, it would have been considered a preoperative visit and not payable under the chalazion removal's global surgical package.

Coders should append modifier -25 to E/M or eye codes to indicate that the visit was separate from that required for the procedure and that a clearly documented, distinct and significantly identifiable service was rendered, according a recent AAPC conference presentation from Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.

When submitting the paper claim, you should not need any additional documentation other than what is usually required for both the minor procedure and the office visit, says Beverly Cilas, CPC, coding specialist with Ford Caserta Eye Center in Tempe, Ariz.

Use One ICD-9 Code Comfortably

Some coders state that you must have separate diagnosis codes for the office visit and the minor procedure in order for them to be considered "significant and separate" procedures.

But experts clarify that the need for two diagnosis codes is a myth. "While using two different diagnosis codes may help with the claims processing, it is not a requirement, and you can bill for an office visit and a minor procedure even if you only have one diagnosis," says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding and reimbursement consultancy. She cites a memorandum published by HCFA, now CMS, concerning the use of modifier -25:

"As part of HCFA's review of these edits, they will address the appropriate implementation of national policy, which allows the same ICD code to be billed for both an E/M service and another procedure billed on the same patient on the same day."

Medicare maintains that you can code modifier -25 "only when the patient's condition requires a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed."

The following rules apply to modifier -25:
 

It may only be used for office visit codes for services rendered on the same day as a minor procedure.

Documentation of both the minor procedure and the office visit is crucial.

Include two diagnosis codes - one for the sign or symptom that brought the patient into the office for the E/M, eye, or consultation service, and another for the condition the physician found and treated with the minor procedure - if they are not one and the same.

Ophthalmology coders should note that modifier -25 is not required when an E/M serviced is performed on the same day as testing services, such as visual field tests, 92081-92083; fluorescein angiography, 92235; and/or fundus photography, 92250. Because these are "considered special tests, not actual procedures, and don't have post-op periods, they are not considered minor procedures," Kuntz says.

The Medicare global surgical package excludes testing services and will pay for tests performed during the postoperative period, as long as it is medically necessary, Duran says.

Jandroep cautions coders that many third-party payers won't pay for office visits when they are billed with a minor procedure on the same day.