Ophthalmology and Optometry Coding Alert

Assign 57, not 25, for E/M prior to a major surgical procedure

Modifiers 24, 25 and 57 all have one special talent--allowing you to code an E/M service on the same day as (or during the global period of) a procedure. But they are not interchangeable, and to avoid denials you need a foolproof method for choosing the correct one.

Ask yourself these questions to decide which modifier will provide the carrier with an accurate picture of the E/M service. Question 1: Does the E/M follow another service? When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code. By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the E/M service is not included in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Remember: You cannot bill separately for E/M-related services during the global period, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. The global surgical package includes routine postoperative care during the global period.

Example: The ophthalmologist performs PRP (67228, Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]) on the right eye. Within the 90-day postoperative period, the patient complains that the vision in his left eye has become blurry.

The ophthalmologist performs an evaluation for this new, distinct problem (that is, the blurred vision in the left eye is unrelated to surgery in the right eye). The physician discovers that the left eye now has bleeding vessels (362.81, Retinal hemorrhage), which must be treated. In this case, append modifier 24 to the office visit during which the ophthalmologist assesses the second eye. Question 2: Was it a 'major' or 'minor' procedure? When the surgeon decides to perform another procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately.

Depending on the length of the procedure's global period, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code, says Karla Hastings, CPC, coder in the Central Billing Office of the department of ophthalmology at Indiana University.

Clue: If the surgeon provides a significant, separately identifiable E/M [...]