Ophthalmology and Optometry Coding Alert

Question: We did a general eye exam at the patient's request within the three-month period after cataract surgery. Another physician had done the surgery and initiated follow-up care. We billed 99212, appending modifier 79, but Medicare rejected the claim. When I called their customer service line, they couldn't tell me which modifier to use -- but they did say it would be 24, 25 or 57. Which one is correct?

South Carolina Subscriber

Answer: If you can document that your visit was for a complaint unrelated to the original cataract surgery, you can report the E/M service with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

Without the modifier, the insurer will assume that the visit was related to the surgery, no matter what diagnosis you report, since the patient is still technically within the postoperative care period of the cataract surgery.

You may need to submit documentation showing that you were investigating an unrelated problem.

Modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 57 (Decision for surgery) would not be appropriate in this case. Modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) is usually appended to surgery or procedure CPT® codes, not E/M or examination codes.