Optometry Coding & Billing Alert

Published on Sun Sep 19, 2004 PDF

Question: A patient presented with a complaint of foreign-body sensation. I found trichiasis and performed epilation. I'm still confused about modifier -25. If I saw the patient for this complaint, how can I justify charging a visit code with modifier -25 along with the epilation when the exam was related to the surgery?

Florida Subscriber

Answer: If this was a new patient complaining of eye pain, the complaint justifies examining the whole eye, even if only trichiasis was found and treated. You can code the appropriate level of E/M visit and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), along with the proper epilation code - for example, 67820 (Correction of trichiasis; epilation, by forceps only). You must document the history, exam and medical decision-making involved in the E/M service first and then do a dated entry for the procedure.

Remember: Even though the expanded definition of modifier -25 states that the diagnosis can be the same for the office visit and the procedure, two separate diagnoses may help clarify for the payer that the office visit is separate from the procedure. If the symptom that brought the patient in for the office visit is linked to the final diagnosis of the procedure, you often find that there are two separate diagnoses.

In your example, link the office visit (with modifier -25 appended) to 379.91 (Unspecified disorder of eye and adnexa; pain in or around eye), and link 67820 to 374.05 (Other disorders of eyelids; trichiasis without entropion) or 374.00-374.04 (Entropion and trichiasis of eyelid) for one of the trichiasis-with-entropion codes.