• Don’t Get Your Modifiers in a Muddle: How to Ace 7 Tricky Scenarios

    By Sue Vicchrilli, COT, OCS, Academy Coding Executive

    This article is from November/December 2005 and may contain outdated material.

    If you can master CPT's modifiers, you not only will boost practice income but also will improve productivity-for you will waste less time following up on rejected claims. Mistakes are often made in documenting and coding the seven scenarios below. Which CPT codes and modifiers would you use?

    1. A surgery patient returns within the postop period for her quarterly glaucoma evaluation.

    Coding. Use 9921X or 9201X for the appropriate level of exam. Append modifier -24 to the exam.

    Tip. The diagnosis code must reflect the glaucoma condition, not the surgical diagnosis. And, most importantly, the first line of the chart note should never state "postop." Your documentation must be clear that the visit is unrelated to the surgery in order to correctly code with modifier -24.

    2. An established glaucoma patient who has been using two types of glaucoma medication presents with uncontrolled IOP in both eyes. An argon laser trabeculectomy (ALT) is performed in both eyes the same day as the exam. Which modifiers would you use for the exam and ALT?

    Coding. For a Medicare patient, use 9921X or 9201X for the appropriate level of exam. Append modifier -25 to the exam because the ALT has a 10-day global period.

    For a non-Medicare patient, use 9921X for the exam. Append modifier -57 to the exam. However, many non-Medicare payers are no longer paying for an exam the same day as a minor/ major procedure.

    In coding for the ALT, you can use either 65855-50 or both CPT code 65855- RT and CPT code 65855-LT (payment will be 100 percent of the allowable for the first eye and 50 percent of the allowable for the second eye, per global surgical rules).

    3. Serial tonometry is performed the same day as an exam. You would use CPT code 92100 for the tonometry plus either 992XX or 920XX for the exam. Would you add modifier -25 to the exam code?

    Coding. Appending modifier -25 is not necessary, and the claim may be denied.

    Tip. Because Medicare and the Office of Inspector General are investigating use of modifier -25, using it in this situation would draw unnecessary attention to your practice.

    4. A patient presents post-trabeculectomy of the right eye requiring additional treatment. He is still within the 90-day global period.

    Coding. Use 68200-58-RT for the subconjunctival injection and HCPCS code J9190 for 5-fluorouracil.

    Tip. Typically four or more injections may be administered several days apart. The injection code has a global period of zero days. You can repeat the above coding example for each day's injection(s).

    5. A malignant eyelid lesion on a patient's left lower lid is excised. The pathology report indicates that additional tissue will need to be removed. During the seventh day of the postop period a larger excision with skin graft is performed.

    Coding. Use 14060-E2-58.

    6. Within the global period of cataract surgery on the right eye, a YAG laser capsulotomy is performed.

    Coding. Use 66821-78-RT.

    Tip. Modifier -78 does affect payment. Payment is 80 percent of the allowable, because of the fact that a new global period does not go into effect. Continue the original 90-daypostop period of the cataract surgery.

    7. Within the global period of cataract surgery on the left eye, cataract surgery on the right eye is performed.

    Coding. Use 66984-79-RT.