By Reginald Sanders, MD, Retina Group of Washington and Georgetown University School of Medicine, George A. Williams, MD, Academy Secretary for Federal Affairs, and Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement
High-volume use of modifiers attracts payer attention. That is one of the reasons retina practices must adhere to guidelines regarding modifiers –25 and –JW, which is used for Triescence.
When to use modifier –25. Suppose you perform an exam on a patient the same day that she undergoes a minor surgical procedure. (A minor surgery is one that has a 0- or 10-day global period). If the exam is a significant, separately identifiable service, then you should append modifier –25 to the E&M or Eye visit code.
Minor retina surgeries. The most common retina procedure with a 0-day Medicare global period is:
- 67028 Intravitreal injection of a pharmacologic agent (separate procedure)
Common retina procedures with a 10-day Medicare global period are:
- 67101 Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy
- 67105 Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
- 67227 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), cryotherapy, diathermy
- 67228 Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation
Note: Commercial payers that do not follow CMS’ global periods may still have a 60- or 90-day global period for codes 67101, 67105, 67227, and 67228. With those payers, the procedures would be considered major procedures (because the global period is greater than 10 days), and you would append modifier –57 to the appropriate level of exam. Modifier –57 indicates that it is the exam to determine the need for a major surgery.
Screen out inappropriate use of modifier –25. Ask yourself this: Even though it was medically necessary, was an established-patient exam performed solely to confirm the need for the minor procedure? If so, the exam should not be submitted for payment.
Unexpected problems. Per comparative billing reports from other specialties, modifier –25 may be appended to exams for unexpected, as well as unrelated, problems.
CPT code 99211 (the E&M “technician code”) cannot be paid if it is billed with a drug administration service. But you can still get paid for an E&M or Eye visit service that is performed in addition to a drug administration service, provided 2 conditions are met. First, it is a medically necessary, significant, and separately identifiable E&M or Eye visit service. Second, it meets a higher level of complexity than CPT code 99211. You would report the appropriate E&M or Eye visit code with modifier –25, and documentation should support the level of exam billed. For an exam provided on the same day, a different diagnosis is not required.
Modifier –JW for Triesence
Beginning Jan. 1, 2017, the CMS mandated use of modifier –JW, when appropriate, to demonstrate wastage on all single-use vials.
In a retina practice, modifier –JW will be used to document wastage of Triesence (triamcinolone acetonide) as follows:
Triescence 40 units
J3300 4 units
J3300–JW 36 units
For all other single-dose vials, with no measurable wastage, the chart documentation should state “any residual medical discarded.”
Learn more about coding for injectable drugs at aao.org/practice-management/coding/injectable-drugs.
Case Study 1
An established patient presents for follow-up of:
- Continued floaters in both eyes, which have decreased in frequency since the last visit.
- Wet age-related macular degeneration (AMD) in the right eye, and a new assessment of left eye for AMD. The patient says that she is doing well and reports no changes in vision at distance and near.
- Dry eyes, which have improved with increased use of artificial tears and with the patient concentrating on improved blinking during computer use.
Plan. Continue to monitor floaters. Optical coherence tomography (OCT) shows marked improvement of the wet AMD in the right eye but still shows evidence of active choroidal neovascularization; stable dry AMD in the left eye. Recommend intravitreal injection today in the right eye. Continue AREDS vitamins and dry eye regimen, adding ointment at night as needed.
Coding. Submit CPT codes for (1) appropriate level of E&M or Eye visit service, plus modifier –25, (2) OCT, (3) intravitreal injection, and (4) drug.
Case Study 2
An established patient presents with a new complaint of decreased, distorted vision in the right eye. The patient’s history includes intravitreal injection in the left eye 2 weeks ago. Vision is slightly improved in the left eye.
The exam shows new neovascular AMD in the right eye. Left eye has active neovascular AMD. OCT and fluorescein angiography confirm neovascular AMD in right eye.
Plan. Patient undergoes intravitreal injection in right eye today.
Coding. Submit CPT codes for (1) appropriate level of E&M or Eye visit code, along with modifier –25, (2) OCT, (3) fluorescein angiography, (4) injection, and (5) drug.
Case Study 3
An established wet-AMD patient returns for a scheduled third intravitreal injection in right eye. The patient reports that her vision is not great but stable.
Plan. Recommend intravitreal injection today. Follow-up in 2 months. OCT next visit.
Coding. In this case, you would not be able to submit an exam code with modifier –25.