Ophthalmology and Optometry Coding Alert

Learn how to use modifiers -24 and -79 with the eye codes Oh, those modifiers! They remain a mystery to many coders who think they know how and when to append them, yet frequently find their claims denied. Steer clear of common modifier pitfalls with our advice from the experts.

The modifier problem is so pervasive that improper use of modifiers has been cited as one of the top-10 billing errors by federal, state and private payers - not to mention that it is considered a major fraud, abuse and noncompliance issue. Enter the Modifier Matrix: Understanding Claims Processing We tend to think of the claims processing system in terms of how it should be done (what makes sense) versus how the computer systems work. For example, when you perform a surgery on the right eye and use the -RT modifier, then follow with a surgery on the left eye and append -LT, you assume that it was obvious that payment for one surgery did not include the other. But the computer processing your claim may not be programmed to distinguish between the right and left modifiers. The -RT, -LT, and   -E1 through -E4 modifiers are "informational" modifiers, not "payment" modifiers.

Consider a case in which you perform a service on one eye during the global period following the same procedure performed on the other eye. When coding the surgical procedure during the postoperative or global period for Medicare reimbursement, if you do not apply a modifier to indicate that the service is either -58 (Staged or related procedure or service by the same physician during the postoperative period), -78 (Return to the operating room for a related procedure during the postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period), the system will process your claim as though what you did was part of the global surgical package.

This can and will happen if the provider number you use is either for the same physician who performed the surgery or for a physician who is a part of the same group practice. The system isn't able to distinguish by physician, procedure code or diagnosis code that an obviously billable service should be paid. "With office visits, the same is true unless you mark the visit as 'unrelated' with modifier -24, 'significant and separately identifiable' with modifier -25, or the 'decision to perform major surgery' with modifier -57," says Raequell Duran, president, Practice Solutions, Santa Barbara, Calif. All ophthalmologists are categorized under the same specialty number, and the system is not able to recognize a glaucoma specialist from a retina specialist - or a visit for an unrelated condition.
 
Enter the modifiers. The little add-ons let the carriers [...]