Wiki Ophthamological exam under anesthesia - 25 or 59 modifier

[lindaskin]

There is a new NCCI edit that became effective 7/1/2009 in which the 92018 is considered part of the major procedure 67210 (and many others). The edit states that a modifier is allowed to unbundle the code pair.
My question is whether the 25 or 59 modifier is most appropriate to append to the 92018

 

[jhartung]

I would say not 25 as this modifier is used for E/M services only. 59 would work, but the procedures would have to be ones that are not normally reported together but are appropriate under the circumstances. I would maybe try modified 51 for multiple procedures.

 

[lindaskin]

92002, 92004, 92012, 92014 are specialized eye exams that are considered as E&M codes by most payors and a -25 modifier is appended to them. 92018 is also a specialized eye exam except it is done under anesthesia. Why wouldn't it use a -25 modifier as well?

 

[deedeefronius]

The reason you would not use the -25 modifier is because the exam is (or shouldn't be) performed in the office setting. It should be done at an inpatient or outpatient hospital or ASC.

If you bill with the POS of 21, 22 or 24 the -25 modifier is not appropriate and the claim could be denied. You should use -59 or -51, which ever one is appropriate.

Hope this helps.