Optometry Coding & Billing Alert

These 3 common optometry scenarios clear up when you can -- and can't -- separately report E/Ms.

When a minor procedure requires additional up-front work, you may be entitled to additional reimbursement - if you have the necessary documentation to append modifier -25 to a separate E/M service.
 
Many private carriers -- unlike most Medicare carriers -- will reimburse for minor procedures and office visits separately with the correct coding and sufficient documentation, says Janine George, office manager for Mallinger & Eger Optometric Associates in Pittsburgh.

The next time your optometrist inserts a punctual plug -- or performs another minor procedure, such as a foreign-body removal -- reference these scenarios to determine whether the carrier should reimburse you for the office visit in addition to the minor procedure, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

Punctal Plugs

Code the procedure with an eye/lid modifier and the office visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). A patient reports dry, itchy eyes and generalized pain. The optometrist performs a complete eye exam -- separate from the procedure -- to rule out other causes, and he diagnoses dry eyes. He places collagen punctual plugs in the two lower puncta to see if this resolves the problem.

Report 68761 (Closure of the lacrimal punctum; by plug, each) on two lines and append -E2 (Lower left, eyelid) and -E4 (Lower right, eyelid), plus modifier -51 (Multiple procedures) to denote the lids. For example, you would report 68761-E2, 68761-51-E4. Link 375.15 (Other disorders of lacrimal gland; tear film insufficiency, unspecified) to the punctual plug closure codes. Also report the appropriate-level E/M service with modifier -25 and link it to 379.91 (Pain in or around eye).

Code the procedure alone. The same patient returns for a follow-up visit in three weeks and reports great improvement following the punctual plug placement. The optometrist replaces the temporary plugs with permanent silicone ones. Report the surgical procedure again, as above, and link it to 375.15 for the dry-eye syndrome. You should not separately report an E/M service when the service was an "integral and preoperative" part of the plug placement.

Foreign-Body Removal

One of the trickiest examples of using modifier -25 is for an office visit with a foreign-body removal.

Many optometrists perform an exam, identify the foreign body and attempt to remove it that same patient encounter. The issue becomes one of documentation, Duran says. The optometrist must document the history, exam and medical decision-making first and then do a dated entry for the procedure.

But when the optometrist makes the mistake of describing the foreign-body removal in the slit-lamp portion of the exam, the exam may appear to carriers as though it is included in the preoperative portion of the minor surgery's global surgical package. (See "Cover All Your Documentation Bases for a Reimbursement Home Run" on page 27 for tips on how to navigate this challenge.)

Code the procedure and the office visit with modifier -25. A patient complaining of pain and tearing presents, and the optometrist performs a complete exam to determine the cause. She subsequently finds a corneal foreign body. The doctor removes the foreign body -- 65222 (Removal of foreign body, external eye; corneal, with slit lamp) -- which you would link to 930.0 (Foreign body on external eye; corneal foreign body). You should then append modifier -25 to an E/M code based on the extent of the service and link it to 379.91.

Code the procedure only. Often a patient, such as a construction worker, will present and know there is a foreign body in his eye. He generally knows how he felt when it started and how the foreign body got in his eye. And he has often tried to remove it himself by trying to wash it out or get the foreign body to stick to a magnet if he knows it was metallic. Under these circumstances, you should only report the procedure code (65222).

Epilation for Trichiasis

Code the procedure and office visit with modifier -25: A patient complains of a red eye and a "scratchy, foreign-body sensation." The doctor does a slit-lamp exam and sees a lash growing in toward the eye causing irritation. He then removes the lash. Report 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.

Code the 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 optometrist looks with the slit lamp to locate only the aberrant lash, agrees, and removes it. You should report 67820 with 374.05, and no office visit.