Modifiers can aid in prompt and correct payment, but can also trigger audits. Medicare and other payers continue to include incorrect modifier usage as one of the top reasons for denials and recoupments. As exams are a high-volume service for ophthalmologists, be sure you are using them correctly.
There are three modifiers that are only applied when billing for E&M exam services or Eye visit codes. Modifiers -24, -25 and -57 should never be applied to another service rendered such as tests or surgeries. Each tells the payer why the exam is being submitted, which impacts reimbursement for the physician.
Modifier -24 is defined as an unrelated exam performed during the global period of a surgery or procedure. Use of modifier -24 is limited to an exam that is NOT related to the reason the patient is already in a postoperative period. Your documentation must clearly indicate why the exam is unrelated; a different diagnosis is insufficient. If the history of present illness indicates a postoperative follow-up, the exam is not reimbursable. For example, use this modifier when your post-operative cataract patients come in 75 days after surgery for their annual plaquenil examination. The history of present illness (HPI) should focus on the reason the patient is presenting, and not include the reason the patient is in the postoperative period.
Modifier -25 is defined as a significant and separately identifiable exam performed the same day as a minor surgery, which is defined by a 0- to 10-day global period. It should be used only when a minor surgery is performed the same day as an exam. Testing services are separately billable and do not require a modifier on the exam. For example, if a patient is scheduled for a diabetes evaluation and also complains of an eyelid lesion that you excise the same day, bill the exam with modifier -25. The exam should only have diabetes diagnosis linked. If a patient was scheduled for a lesion evaluation and an excision was performed the same day, the exam itself is likely not billable as the excision includes the pre-operative work-up for the service and procedure.
Remember, effective July 1, 2013, Correct Coding Initiative edits, which bundle some services performed the same day, bundle all established patient exams with minor and major surgeries. If an exam and surgery are performed the same day, a modifier, such as -25 or -57 is needed to break them when the exam should be separately paid.
Medicare Part B does not require modifier -25 to be appended to new patient exams as the surgeon needs to establish care. However, other payers may require the modifier be appended to the exam or they may bundle the exam into the surgery. While medically necessary, if the established patient exam is performed solely to confirm the need for the minor surgery, it is not separately billable. The office visit must go above and beyond the usual pre- and postoperative care associated with a minor procedure. Look at the reason the patient presented, what exam elements are necessary and the plan to help confirm whether the exam should be separately billed.
Modifier -57 is appended to an exam when the decision to perform a major surgery was made at this encounter. The major surgery, defined by 45-, 60- or 90-global period, is performed either the same day as the exam or the day following. Some payers allow up to 48 hours later. The global surgical package states exams performed the day before and the day of surgery are included in the surgical billing. As the decision to perform a major surgery is separately reimbursable, this modifier allows you to bill for the service. For example, if a patient comes in with ruptured globe, and you repair it that day, make sure you use modifier -57 so your clinic examination is paid.
One area we see delays in payment is due to submitting for the exam without appending modifier -57. Be sure your billers are aware if a surgery is to take place the following day, so they correctly use modifiers and submit a clean claim.
Test Your IQ on Billing with Exam Modifiers
Q1. A 3-year old boy presents with recurrent lumps right upper and left lower eyelids. His parent’s attempts with warm compresses have provided no relief. The surgeon determines that the chalazia should be excised and schedules CPT code 67808 Excision of chalazion; under anesthesia and/or requiring hospitalization, single or multiple for the next day. What modifier, if any, should be appended to the exam?
A1. Modifier -57 should be appended as this is a major surgery.
Q2. A new Medicare Part B patient presents to the practice and the physician diagnoses Molluscum contagiosum. During the encounter, the surgeon performs CPT code 17110 destruction, up to 14 lesions. What modifier, if any, should be appended to the exam?
A2. As this is a Medicare Part B patient, no exam modifier is required since the patient is new. For other payers, some physicians may try submitting modifier -25 if the exam went beyond the reasons for the minor surgery and was more in-depth.
Q3. A patient in the postoperative period of cataract surgery in their right eye comes in after being hit with a branch in the same eye while gardening. Should modifier -24 be appended to the exam?
A3. Yes, as this is unrelated to the reason the patient is in the global period. The exam and medical decision-making should focus on the new problem. Avoid appending the cataract or pseudophakic diagnosis on the claim.
Additional information on modifiers can be found in the Learn to Code the Essentials and 1-Hour Online Course: Modifiers Made Easy-Your Guide to Correct Coverage.
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She also is a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.