Optometry Coding & Billing Alert

Question: I know that I can use modifier 59 to unbundle codes under the right circumstances, but which code should I attach it to - the one in column 1 or column 2 of the edits?


New Jersey Subscriber

Answer: You should always append modifier 59 (Distinct procedural service) to the lesser-valued code - regardless of the order in which the optometrist performed the procedures. Depending on what kind of bundle the codes are in, the lesser-valued code may be in column 1 or column 2 of the National Correct Coding Initiative (NCCI) edits.

If the codes are in a "Comprehensive/Component" or "Column 1/Column 2" bundle, such as 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services), NCCI considers the procedure or service in column 2 (99211) an intrinsic part of the procedure or service in column 1 (92225). For these edits, the code in column 2 is usually the lesser-valued one.

In this case, you would leave the column 1 code, 92225, which has 0.61 non-facility RVUs in the current fee schedule, unmodified, and report it first. Append modifier 59 to the column 2 procedure, 99211 (0.57 nonfacility RVUs), and report it second.

Hidden trap: In a "Mutually Exclusive" edit, NCCI does not expect that the two codes would ever be medically necessary together. If you report two mutually exclusive codes together without an appropriate modifier, Medicare carriers will only pay for the code in column 1. And to discourage you from trying to report the two codes together, NCCI places the lesser-valued code in column 1 of the mutually exclusive edits.

Example: A mutually exclusive edit places 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) in column 1, and 92250 (Fundus photography with interpretation and report) in column 2.

To unbundle these two procedures, report 92250 (1.99 RVUs) unmodified and append modifier 59 to 92135 (1.16 RVUs).

Advice for Reader Questions and You Be the Expert contributed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas; and Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.