I saw a college student with glaucoma. We decided to do trabeculoplasty by laser surgery (SLT) in one eye the same day as the exam since they were leaving for college the next day. Am I able to bill CPT codes 65855 and 99214 on the same date of service?

Answer:
The first question to ask is: Who’s the payer? What global period does the payer recognize for CPT code 65855? Medicare assigns a 10-day global period. The global period for commercial payers could be 10 days or could be 90 days.

If the procedure has a 10-day global period, the documentation for the evaluation and management code must meet the definition of modifier -25 (Significant, Separately Identifiable Evaluation and Management Service by the same physician on the same day as a minor procedure) to append and bill on the same date of service as the laser.

Modifier -57 (Decision for surgery) would be appended to the office visit when a SLT is performed the same day for a payer that recognizes a 90-day global period for this procedure.

Comprehensive training on modifiers can be found in chapter 5 of Fundamentals of Ophthalmic Coding.