• Recent CCI Edits Significantly Impact Ophthalmology

    Effective July 1, Correct Coding Initiative (CCI) edits version 19.2 bundled all established patient exam codes (both E&M and Eye codes) with all major and minor surgeries.

    This impacts established patient exams appended with either of the following:

    • Modifier –25: Significant, separately identifiable E&M code (and Eye code) by the same physician or other qualified health care professional on the same day of the procedure or other service
    • Modifier –57: Decision for surgery

    Unfortunately, CMS has not given Medicare administrative contractors clear direction on how to implement these new edits or contractors have not adopted the corrections. As a result, exams are being denied. Also, several sources have provided erroneous information about the edits.

    Why did the edits occur?

    The edits occurred in part because previous audits found cases where patients exams were billed separately from the surgeries to which they were related. By definition, modifier -25 may only be used to unbundle an exam that is significantly, separately identifiable from the minor procedure performed on the same day. Medical necessity is not sufficient reason to bill an exam separately. If the exam is performed solely to confirm the need to perform the minor procedure, it is not a billable exam. 

    When is unbundling appropriate?

    When the established patient exam is completely unrelated to the surgery and would have been performed even if the patient had no other procedure that day.

    How do I unbundle?

    Modifier –25 should unbundle the established patient exam from the minor procedure performed on the same day.

    Modifier –57 should unbundle the established patient exam from the major procedure when the exam is performed the same day as the major (90 postoperative days) procedure

    What is the Academy doing about the edits?

    The Academy immediately reached out to all its contacts at CMS on both the state and national level and enlisted the help of its ophthalmic carrier advisory committee contacts. The Academy has also contacted other medical specialties impacted by these edits.

    What to do in the meantime?

    There are three options until CMS publishes further guidance:

    1. Hold the exam and minor procedure.
    2. Hold the exam and submit the minor procedure. In the case of intravitreal injection, submit the injection and the drug.
    3. Submit the claim, and if inappropriately denied, prepare to appeal only after CMS has internally fixed the problem.

    Should Medicare staff recommend appending modifier -59 to the exam to identify it as a separate procedure, do not follow this advice until you see it in writing. Modifier -59 is not intended to append to exams and may be the trigger for future Recovery Audit Contract (RAC) audits.

    CCI Edits Detailed

    In addition to the bundling of established patient exams with all major and minor surgeries, CCI edits also contain the following changes:

    CPT Code Bundled With:
    92225 Extended ophthalmoscopy
    92226 Subsequent ophthalmoscopy
    67005, 67010, 67015, 67025, 67027, 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67115, 67120, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67225, 67227, 67228, 67229
    64612 Chemodenervation of muscle(s): muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm) 62310, 62311, 62318, 62319, 64400, 64402, 64405, 64408, 64410, 64412, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450, 64479, 64483, 64490, 64493, 64505, 64508, 64510, 64517, 64520, 64530

    Each of the edits has an indicator of “1,” which means the bundle can be broken by appending modifier –59 to 92225, 92226 or 67612 when the definition of modifier –59 Distinct procedural service is met. This means that a procedure or service was distinct or independent from other services performed on the same day. It may represent a:

    • Different patient session or encounter;
    • Different procedure or surgery site;
    • Separate lesion or
    • Separate injury.

    To view CCI edits in their entirety, visit the Academy’s Coding Tools.

    CCI Edit FAQ

    Question Answer
    Will commercial payers adopt these edits as well? Currently some payers don’t pay for an established patient exam the same day as a minor or major surgery. Their rationale is that 10 percent of the surgery allowable is for “preoperative assessment” and practices are being paid — just not paid separately.

    As for the other payers, only time will tell.
    Which modifier(s) are appropriate to use when you bill for an exam with an injection? Our understanding is it would go as follows:
    92014, Modifier –25 and –59; 67028, Modifier –RT and 67028, Modifier –LT.
    Several issues exist here:

    1. Make sure documentation supports the medical necessity for a comprehensive exam the same day as injections. The exam must be significantly, separately identifiable from the exam performed the same day as the injection. If the exam is performed solely to confirm the need to inject, it is NOT separately billable.  
    2. Do NOT append modifier –59; it should never be appended to an exam. By appending modifier –59, you may erroneously override the bundling edit. This practice may subject you to a future Recovery Audit Contractor audit.

    3. As with recent, medically unlikely edits, bilateral drug injections should be submitted as 67028–50. Otherwise, the claims will be denied. Double your charge. Payment will be 150 percent of the allowable — just as when billing with –RT/–LT.
    Is it appropriate to obtain an Advance Beneficiary Notice (ABN) from the patient and collect the fee for the exam since it is not separately payable at this time? No. This is inappropriate use of the ABN.  

    The exam that meets the documentation requirements for modifier –25 will be paid by Medicare Part B as soon as clear direction is provided.

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    About the author: Michael X. Repka, MD, MBA, is the Academy’s medical director of government affairs. Cherie McNett, is the Academy’s director of health policy. Sue Vicchrilli, COT, OCS, is the Academy’s coding executive.