Optometry Coding & Billing Alert

Question: A patient came to us for punctal plug insertion. He also complained about pain in his eyes. We performed a separate E/M to diagnose the problem. Can we code the E/M separately?

California Subscriber

Answer: Yes, you may report the E/M separately if you meet certain criteria.

You should first check that your chart note supports billing the E/M with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). You have to prove that the E/M was a significant, separate service from the punctal plug insertion because every procedure has a small E/M already built into it.

Tip: Ask yourself whether the E/M documentation -- which should also indicate medical necessity for the E/M -- would stand alone for payment if you hadn't inserted the punctal plugs.

Watch for: You may determine that another coding option, such as ophthalmic exam codes 92002-92014, suits a particular service better than an E/M code. Always report the code that is appropriate for your service.