Ophthalmology and Optometry Coding Alert

Question: A patient of ours is in the global period for a YAG laser procedure. She came in for a follow-up with symptoms of foreign-body sensation and irritation in the right eye. The ophthalmologist performed epilation with forceps to remove lashes from the lower right lid. What modifiers would I use in this case? Normally, I would append modifier 25 to the exam, but since the procedure is still in the global for the YAG, would I need 24 instead? Do I need a modifier for the epilation procedure?

Codify Subscriber

Answer: To code this visit, you must remember that you are in the global period of the YAG capsulotomy(66821, Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]). So to report the unrelated office visit, you need to append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period).

Next:  The lash epilation starts a new, minor-procedure global period. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M or eye exam code to illustrate that your office visit was significant and separately identifiable from the minor procedure (67820, Correction of trichiasis; epilation, by forceps only).

Finally: Append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to the epilation to show that the minor procedure was not related to the YAG postoperative period and that it was not a complication. Append modifier E4 (Lower right, eyelid) to 67820 to identify the eyelid.

Code for these services as follows:

• 9921x or 9201x -24-25
• 67820-79-E4.