Wiki Modifer Confusion

[Mferbeyre]

Hello everyone
This is my very first post so please let me know if I am posting this question in the right forum thread...
I work for an ophthalmologist, and there has been some confusion lately with modifier 25 and 57. I have read numerous articles, and printed out papers to try and get a better understanding in plain English lol it seems like these sights and articles love to run around in circles with their explanations of these modifiers and it makes me crazy! Anyway, my question is:
When a major procedure (ex. 66821) and a 92014 are billed on the same date, and the laser has been previously scheduled. Can the two CPT codes be billed together? And would the E/M get a modifier be 25 or 57?

The articles I have printed say that modifier 25 should be used with minor procedures. When the office visit results in a decision for that minor procedure. My understanding of this is if the patient comes in because they have scheduled a minor procedure (ex. 65855), and the doctor sees the patient prior to the surgery, and is also evaluating the patient for other issues... like retinal hypertension or something. Then we would use the -25 on the E/M.
These same articles also say that modifier 57 should be used on the same day or the day before a major procedure and that results in the decision to perform the surgery. My understanding of this is if the doctor sees the patient for cloudiness after cataract surgery, and determines the patient needs a 66821 either that day or the day after, then the -57 would go on the E/M code.
Is my understanding correct?
Or IF the 66821 is scheduled lets say a week in advance then none of these modifiers qualify, and we shouldn't be billing an office visit and a procedure on the same date?

Any and all help would be greatly appreciated

 

[Orthocoderpgu]

Full disclosure: I work in orthopedics. Modifiers -25 & -57 communicate to the insurance company to not deny an E/M visit because the decision for the surgery was made during that visit. Now, if the patient is coming in specifically to have a procedure performed you should not be routinely billing office visits on the same day. If the provider does evaluate and manage a condition that is not related to the surgical procedure, then an office visit can be billed as well with a modifier. But again, this should not be a routine circumstance either. Example from my neck of the woods: A patient sees a physician for shoulder pain and during that visit the physician decides to perform a joint injection to treat the pain (20610), then the office visit (99213) would be billed with -25. But if the patient comes in for a scheduled shoulder injection, only the injection would be billed.

Your asking about 66821 & 92014. While 66821 is a surgical procedure with a 90 day global, code 92014 is not an E/M code. At least in the traditional sense. If a patient is coming in to have 66821 performed, adding -57 to 92014 would be inappropriate since the decision to perform the surgical procedure would already have been made.

There is much more on this topic but I hope that this is enough to give you direction for now without going totally crazy.

 

[Mferbeyre]

@Orthocoderpgu that is exactly what I thought! I kept saying no office visit should be billed on the same day of any procedure unless it is like your case. Where the patient came in for a separate reason, and the doctor decides to perform a procedure. Then the modifier would apply depending on the global period. Thank you!!

 

[Orthocoderpgu]

@Orthocoderpgu that is exactly what I thought! I kept saying no office visit should be billed on the same day of any procedure unless it is like your case. Where the patient came in for a separate reason, and the doctor decides to perform a procedure. Then the modifier would apply depending on the global period. Thank you!!

Here is another thing that is confusing to me. Why would you be billing 92014 on the same date as 66821? That makes no sense. It seems to me that you would have a comprehensive eye exam where the need for the surgical procedure (66821) would be identified and then the procedure would be scheduled afterwards. Now, every procedure has a "built in" E/M component (even the 10 day global procedures) to make sure that the patient can tolerate the surgery per se. If your coming in for surgery, why would you need to have such a comprehensive eye exam?