Ophthalmology and Optometry Coding Alert

When the diagnosis is the same or similar for an office visit and minor surgery, commercial insurance plans may deny the claim. When performing an audit, Medicare will make sure that the office visit is significant and separately identifiable from the minor surgery, whether the procedure is starred or not.
 
CPT states that starred procedures are separate procedures. Some payers may interpret this to include the E/M services unless special circumstances exist, explains Ann Rose, president of Rose and Associates, an ophthalmology coding and compliance consultancy based in Duncanville, Texas. Denote special circumstances by appending modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code (99xxx), indicating a service was performed that is separate and beyond what the preoperative procedure required.
 
Keep two things in mind when using modifier -25:
 
1. Documentation of the minor procedure is key; the elements of the exam that constitute the E/M service are a matter of local medical review policy.
 
2. Link the diagnosis code for the sign or symptom that brought the patient to the office to the E/M service and the diagnosis code for the condition the physician found and treated to the minor procedure.
Four common procedures foreign body removal, chalazion excision, epilation for trichiasis, and punctal plug placement sometimes require additional up-front work by the ophthalmologist, as represented by a billable office visit and modifier -25.
Foreign Body Removal
One of the trickiest examples of using modifier -25 is foreign body removal (65205-65222, 67938, 68530). Consider the patient's chief complaint and the nature of the exam before deciding whether to check off "office visit" on the superbill, Rose recommends.
 
Most ophthalmologists perform an exam, identify the foreign body and attempt to remove it. "In the case of foreign body removal, the standard of physician practice is to examine the eye and remove the foreign body on the same day," says Raequell Duran, president of Practice Solutions, an ophthalmology reimbursement and coding consultancy based in Santa Barbara, Calif. "The issue becomes one of documentation." Document the history, exam and decision-making first and then do a dated entry for the procedure.
 
Many ophthalmologists make the documentation mistake of describing the foreign body removal in the slit lamp portion of the examination, which makes the procedure appear to be the same as the visit, Duran says. That documentation makes it virtually impossible to bill the procedure and the E/M service, even though both codes are otherwise justified.
 
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