Wiki 25 modifier - new to ophthalmolgy

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ktrek32

ktrek32

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I am new to ophthalmolgy and the person that trained me I am thinking was not all correct on all the OV 99212-99214 there is a 25 modifier and on all the diagnostic tests for example 92250 or 92134 or 92133 or VF 92083 all have a 59 modifier on them. does the 25 modifier need to be used and does the 59 modifier need to be used. thanks for any help that I can get
 
25 modifier

The -25 modifier should suffice. Make sure there is documentation for the E/M visit as well as the procedure. You can always use the NCCI tool from Medicare to confirm.
 
The 25 modifier is used to show a separately, identifiable visit so it wouldn't be appropriate to use for every office visit in which you also do a test. We use the 25 mod if for example, when a patient comes in for an office visit and glaucoma testing and the patient has a foreign body in the cornea. So we do:

Office visit with 25 mod with glaucoma ICD9 codes (reason for patient's visit)
Glaucoma testing CPT with glauc dx codes
FB removal CPT with FB dx code

We typically don't use a 59 on the testing, but we have found some payers require 51 mod if we do multiple tests.
 
thank you so much for your help that was the way I thought the billing was supose to be done but the person that trained me does not think that is the way so she keeps changing my billing so now I have others who think correct coding is the same way as I do so that will help, just because an insurance pays does not mean that it is correct and that is what I am trying to show her
 
Typically if it is testing you don't need a -25 on the office visit. Only if a procedure has been done would the office visit need to be identified as separate.
 
I am having a similar issue and am new to ophthalmology coding. The denial that I am getting is when billing 99214, 92083, and 92133 altogether. the 92133 had a 59 and medicare is still denying. Do I need a 25 with the 99214
 
you may not meet criteria to do 92083 AND 92133 on same DOS. You need to check your carrier's LCD for dxs, frequency, when both tests would be covered, etc. I believe you also need to code severity of glaucoma for the 92133.
 
Regarding the 25 modifier and testing...........What is your POS? If it's 11 (office) then you don't need 25 on OV when there's a test (only when a surgical code is done same day). There are also strict guidelines for unbundling these two services.

If you're in a facility setting (outpatient), POS 22, then 25 goes on the visit for the hospital when there is also a diagnostic test on the same day.
 
Optometry

I bill for an optometry office. We do a lot of routine eye exams, but if the patient has a medical dx that warrants a 92250 we bill that with a 25 mod when billing medicare. so for example we will bill a 92014 92015 92250 w/ 25 mod dx 250.00. Is this correct or do we need to turn the 92014 into an ov (99211-99215)? Also, my doctors where told at an optometry meeting that if we are billing health insurance (and not vision) to bill ov codes and not to use routine codes. All medical ins has paid either way as long as it was medically necessary.
 
I can clarify a lot of your ophthalmology/optometry coding questions as I code and audit this specialty each and everyday. I also manage a ophthalmology/optometry practice in the day.

Please email me : mzkandyd@gmail.com and I would be more than happy to answer your questions.
 
I am new to Opthal. We don't add -25 to E/M or 92002-92014 when also billing for diagnostic tests 92133-34, 92250. No issues were brought up to our attention.
 
You don't need a 25 modifier when you are doing diagnostic testing on the same DOS.You only use the 25 modifier when you are billing a separate E/M SERVICE, such as a foreign body removal. Most carriers will not reimburse for the 92250 and 92133/92134 being done on the same DOS because they are both considered imaging procedures which image the same part of the eye. Theoretically, according to the CCI edits, you can bill those two tests on the same DOS if you use a 59 modifier. However, I would STRONGLY encourage you NOT to do that since over use of the 59 modifier may make you an audit target.

Realize one other thing that many providers and billers don't pay attention to. It's called MPPR (Multiple Procedure Payment Reduction). If you do more than one diagnostic test on the same date of service, Medicare, and other carriers, will pay you full fee for the higher reimbursing procedure but will reduce the reduce the reimbursement for the second test by anywhere from 50% up to 100%. I know that most providers want to decrease the number of times a patient has to return to their offices. However, for chronic conditions, such as glaucoma and AMD, where you see a patient every few months, there is no reason to stack multiple tests on the same DOS. Do one test at one visit and then do the other test at the next visit.
 
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