Ophthalmology and Optometry Coding Alert

Question: A patient came in during the global period for a procedure on her left eye with a complaint relating to the right eye. The ophthalmologist performed an intra-

vitreal injection on the right eye in addition to the office visit and testing. Because this visit was an exception to the global period, but the E/M service was separate and distinct from the injection, should I append modifier 24 or 25 to 99213?

Answer: You should append both modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and 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 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter).

You need modifier 24 to separate the E/M service from the global period of the prior surgery, and you also need modifier 25 to show that the E/M service is distinct from the intravitreal injection the ophthalmologist performed that day.

You should also append modifier RT (Right side) to clarify to the carrier that the ophthalmologist is not caring for the eye that previously had surgery. On the claim form, report 99213-24-25-RT.

Don’t miss: Append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 67028 (Intravitreal injection of a pharmacologic agent (separate procedure)) to show that the injection was also not related to the earlier surgery. Append RT to 67028 as well.