Correctly using modifiers can make or break your practice. Test your own coding knowledge with these five questions from a recent American Academy of Ophthalmic Executives webinar, Mastering Modifiers.
1. True or false: You see a glaucoma patient, and submit the visit with CPT code 92012 Established patient intermediate exam, plus a visual field. You must append modifier -25 to the exam.
2. During the global period of a cataract surgery, an exam of the same eye shows that the patient needs a YAG capsulotomy. Can you bill for this exam?
A. No, the exam is considered postop and not separately billable.
B. Yes, this is a billable exam because you made a new diagnosis.
3. A patient underwent a repair of a retinal detachment with photocoagulation (CPT code 67105 -RT). During the global period, you determined that the patient also needed a scleral buckle (CPT code 67107). How should you submit this scleral buckle?
A. 67107 -58 -RT
B. 67107 -78 -RT
C. 67107 -79 -RT
4. True or false: You must append modifier -24 to any testing service performed during the global period of an unrelated procedure.
5. When epilating lashes (senile) on all four lids, which of the following should you submit with CPT code 67820?
A. Modifier -50
B. Modifiers -E1, -E2, -E3 and -E4
C. Modifiers -RT and -LT
D. No modifier because payment is per session
1. B. False. You should only append modifier -25 to exams. This applies to both E&M and Eye visit codes. Modifier -25 is defined as a significant and separately identifiable exam given the same day as a minor procedure. To determine if you should use modifier -25 for an exam performed the same day as a minor procedure (one with zero or 10 days of postoperative care), ask yourself this question: While medically necessary, did I perform the established exam solely to confirm the need for the minor procedure? If not, append the exam with modifier -25. Be sure to correctly link the diagnosis for the exam separately from the minor procedure.
2. A. Because the capsulotomy is related to the cataract surgery, the exam is considered postop. You cannot separately bill for it. Be sure to submit the YAG with modifier -78, indicating it’s related to the procedure for which the patient is in the postoperative period.
3. A. Choosing between modifiers -58 and -78 can cause some confusion. Because this was a more extensive procedure performed during the global period of the first, you should append modifier -58. This can be referred to as a greater procedure following a lesser procedure, as it was related. When modifier -58 is appended, reimbursement is 100 percent and a new global period begins. Modifier -78 would be appropriate if the case did not meet the definition of modifier -58. Had you chosen modifier -78, you would be reimbursed 70 percent of the allowable, since payment covers only the intraoperative portion of the procedure.
4. B. False. Modifier -24 is defined as an unrelated exam by the same physician during the postoperative period. You should never append it to testing services or procedures. The documentation of the history of the present illness, exam elements and medical decision-making must clearly indicate why the exam is unrelated to the surgery. Payers may request the chart notes for clarification.
5. A and C. Epilation is paid per eye, not per lid. Medicare Part B states that, for bilateral procedures, you should submit one line with modifier -50, one unit and double the amount. Commercial payers may require two lines with -RT and -LT. It’s best to check with each commercial payer to confirm their requirements.
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About the author: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also 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.