Optometry Coding & Billing Alert

Assign 57, not 25, for E/M prior to a major surgical procedure

Modifiers 24, 25 and 57 all have one special talent -- allowing you to code an evaluation and management service on the same day as (or during the global period of) a procedure. But they are not interchangeable, and to avoid denials you need a foolproof method for choosing the correct one.

Ask yourself these questions to decide which modifier will provide the carrier with an accurate picture of the E/M service.

Question 1: Does the E/M follow another service? When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.

By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the E/M service is not included in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Remember: You cannot bill separately for E/M-related services during the global period, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. The global surgical package includes routine postoperative care during the global period.

Question 2: Was it a -major- or -minor- procedure? When the surgeon decides to perform another procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately.

Depending on the length of the procedure's global period, you should append either modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code, says Karla Hastings, CPC, coder in the Central Billing Office of the department of ophthalmology at Indiana University.

Clue: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero-day, 10-day or -XXX- global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CCP, coding specialist in Marietta, Ga.

Modifier 24: Conditions for Use

When you report modifier 24, the E/M service must meet these criteria:

- The E/M service occurs during the postoperative period of another procedure.

- The current E/M service is unrelated to the previous procedure.

- The same physician (or tax ID) who performed the previous procedure provides the E/M.

Note: This is true even if the two physicians have different specialties or sub-specialties, says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif.

If the comprehensive optometrist who performs a cataract surgery refers the patient to a retinologist in the same group for the evaluation of a retinal detachment, modifier 24 is still necessary. Medicare does not make a distinction between subspecialties or use of ICD-9 codes.

Modifier 25: Conditions for Use

When you append modifier 25, the E/M service must meet these requirements:

- The E/M is significant and separately identifiable from any -inherent- E/M component included with other services/procedures you report on the same day. The office visit is not merely preoperative in nature or an integral part of the minor procedure.

- The E/M may be related or unrelated to other procedures/services you report on the same day.

- The service/procedure the surgeon provides on the same day as the E/M service should have a zero-day, 10-day or -XXX- global period.

- The same physician bills the E/M and other procedures/services on the same day.

Modifier 57: Conditions for Use

To properly append modifier 57, remember these points:

- The E/M service must occur the day of or the day before a major surgical procedure (a procedure with a 90-day global period).

- The E/M service must prompt the surgical procedure that follows.

- The E/M service must be related to the procedure that follows.

- The same physician (or tax ID) provides the E/M service and the surgical procedure.

You should report both the surgical procedure and the examination that led to the decision to perform the surgery(for example, 99214). You should append modifier 57 to 99214 to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package for the retinal detachment repair, leading to a loss in reimbursement. Without the modifier, the visit will appear to be the preoperative visit that is included in the global surgical package.

However, when you correct your claim by appending modifier 57, you should be paid for the visit. Many Medicare carriers have a dedicated review line that you can call to add the missing modifier, and payment is usually processed between 10 and 14 days.