Ophthalmology and Optometry Coding Alert

Avoid modifier 25 scrutiny with proper 'separately identifiable' documentation.Reporting a separate E/M every time your ophthalmologist performs a procedure is asking for an audit. Unlock the secrets to legitimate pay for separately identifiable E/M services using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with these three guidelines.1. Ensure Your Ophthalmologist Performed a Separate Service You should use modifier 25 when your ophthalmologist's documentation supports that he performed an E/M service that was significant and separately identifiable from the work included in another service or procedure.Tip: "Look at the documentation and cross out anything that is directly related to the procedure performed," says Judith L. Blaszczyk RN, CPC, ACS-PM, compliance auditor with ACE consulting in Leawood, Kan. "Look then at the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary."Official [...]