Optometry Coding & Billing Alert

Different-diagnoses stipulation may not apply to E/Ms and minor procedures

If you-re looking for guidance on when it's appropriate to append modifier 25 to an E/M or eye exam code, take heart -- help from Medicare is coming.
 
After learning from the Office of Inspector General that it had made $538 million in improper payments on incorrect modifier 25 claims in 2002, Medicare is revising the Medicare Claims Processing Manual to clarify when you can -- and cannot -- append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
The OIG study found coding and billing errors in 35 percent of the claims including modifier 25 that it studied. (To learn more about the OIG study, see -OIG Alert: Reserve Modifier 25 for Separate E/M HEM- in the March 2006 Optometry Coding & Billing Alert.)
 
Key: In response to the OIG study, CMS released Transmittal 954 on May 19, specifying that modifier 25 is used in cases -when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service.- The transmittal also contains revisions to Chapter 12, Section 30.6.6 (B) (-Payment for Evaluation and Management Services Provided During Global Period of Surgery: CPT
Modifier 25-) of the Claims Processing Manual.
 
None of these changes is major, says Lisa Center, CPC, coder with Mount Carmel Regional Medical Center in Pittsburg, Kan. But it's safe to say that modifier 25 -will be under more scrutiny.-

Append 25 Only for Same-Day Services

The revisions, effective June 1, clarify that:
 
- Coders should only append modifier 25 to E/M services.
 
- Coders should only use modifier 25 when the same optometrist provides E/M services to the same patient on the same day as another procedure or service.
 
- Different diagnoses are not required for reporting the E/M service and the procedure done on the same day.
 
- The optometrist must document both the medically necessary E/M service and the procedure in the patient's medical record, even though you don't need to send the documentation with the claim.
 
Tactic: In the documentation, -keep one page for the E/M and another page for the procedure,- says Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.
 
-This sits well with Medicare and causes the optometrist to really be concerned with the documentation of each service,- he says.
 
Get the facts: To read the transmittal and change request, visit www.cms.hhs.gov/transmittals/downloads/R954CP.pdf. To read an MLN Matters article about the revisions, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM5025.pdf. You can access the entire Medicare Claims Processing Manual (CMS publication 100-04) at www.cms.hhs.gov/Manuals/IOM/list.asp.