Optometry Coding & Billing Alert

Question: Whenever I use modifier -25 on an E/M service, with a procedure code on the same claim, payers deny the claim. Should I stop using this modifier? If I appeal the claims, how can I make sure I get paid for at least some of the claims?

Delaware Subscriber

Answer: You should appeal your modifier -25 denials, because you deserve payment for those E/M services. But before you appeal, make sure you're correctly appending modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). When you appeal your claims, send a copy of the chart notes to prove that the E/M service was, in fact, a separately identifiable service, says Mary Dykstra, RT, CPC, billing manager at Medical Center of Stafford in the Roanoke, Va., area. You should have success with these appeals. When Dykstra's office appeals the modifier -25 claims with chart notes, the denial gets reversed, and the claims paid 95 percent of the time.

You should, of course, send the chart notes the first time, but they often get overlooked or lost, she says. If payers see the charts on an appeal, they'll probably pay attention to them since they explain the reason for appeal.

If you're still having trouble getting your claims paid, contact the payer's representative. Dykstra was having trouble with a claim documenting a physician's ankle-sprain treatment and separate E/M service for ear irrigation. Blue Cross Blue Shield had denied the claim, stating that the ear irrigation was incidental to other procedures on the same day. Dykstra called the BCBS representative, who informed her that BCBS doesn't recognize that modifier or E codes.