For such petite codes—just two digits long—CPT modifiers can cause big problems. The trouble is that there are dozens to choose from, and the wrong choice can lead to denied claims, lost reimbursement and, in the worst cases, an audit. Indeed, one current study by the Office of the Inspector General focuses on modifier –25, which is used to indicate a significant, separately identifiable E&M service. Here is a guide to using modifier –25 appropriately.
The most common mistake. The CMS reports that the No. 1 billing error is that of incorrectly appending modifier –25 to the minor surgical code. You should always append it to the office visit code.
Global period. Modifier–25 is most often associated with procedures that have a minor global period, which is defined as zero or 10 days of postoperative care. The latest edition of CPT eliminates the (*) indicator that had previously been used to flag some, but not all, minor procedures.1
Correct Coding Initiative. Comprehensive codes that are bundled in the CCI may be unbundled when medically indicated. When the bundled codes have no global period—for example, a testing service—or if the global period is zero or 10 days, you must append modifier –25 (not –59) in order to unbundle the procedures.
Suppose, for instance, you are unbundling CPT code 99211 with special ophthalmic testing services. In this case, documentation must be exceptional. The physician asks the patient to return for a visual field and documents instructions for the technician to record visual acuity, measure IOP, record drops/time/type, and perform 92083 visual field extended examination. The correct coding would be 99211–25 and 92083.
In another example, a patient is seen for a glaucoma check in the morning. Later that day, the patient returns to the office for a separately identifiable visit due to having been hit in the eye with a racquetball. By appending modifier –25 to the second visit code, you are alerting the insurance company that the visits occurred at two separate times on the same day. The diagnosis codes will identify the two separate reasons for the visits.
Non-Medicare payers. The Academy has received reports that a few non-Medicare payers refuse to cover both services on the same day. You should appeal those cases.
Example of appropriate use. Suppose a patient presents with a complaint of photophobia, pain and foreign-body sensation of the right eye. An exam is performed to determine the cause. The appropriate level of E&M or Eye Code should be billed and appended by modifier –25. CPT code 65222 removal of foreign body, corneal, with slit lamp is used. While Medicare does not require two separate diagnosis codes, other payers may.
Example of inappropriate use. If a chalazion is diagnosed and the physician prefers to wait to see if heat and massage treatments are successful before considering excision, only the appropriate level of E&M or Eye Code would be billed.
If heat and massage did not resolve the chalazion and the patient returned for excision, only the excision CPT code 67800–67808 would be billed.
A significant, separately identifiable E&M service by the same physician
on the same day of the procedure or other service.
1 See February’s Savvy Coder at www.eyenetmagazine.org/archives
Demystifying Modifiers, Part 2: When to use modifier –58.