• Telling a Story with Modifiers: A Primer on Coding

    What do you need to know about modifiers? Everything … period. Applying modifiers is like telling a story to the payer — they indicate that the exam, test and/or surgery billed has been altered or modified in some way. And for claims to be paid correctly, they are vital. Their incorrect usage — as well as their absence altogether — are two major reasons payers reject claims. As a result, modifier misuse can severely impact your practice’s bottom line.

    Deciphering the Story

    Take this example of a CMS 1500 form listing the following CPT codes: 99214–57, 92235–RT, 92250 and 67228–RT. What does all of this signify? Let’s break it down. It means the doctor performed a Level 4 established patient E/M service to determine the need for panretinal photocoagulation surgery — which has a 90-day global period — the same day as surgery in the right eye. He or she also performed fluorescein angiography of both eyes, but submitted only the right eye procedure because the left eye did not have pathology. In addition, fundus photographs were taken on both eyes. As an inherently bilateral test, payment is for one or both eyes, which is why only one CPT code was billed without appending any modifiers.

    The Two Levels of Modifiers

    Always keep in mind that there are two different types of modifiers: Levels I and II. Level I modifiers consist of a two-digit number ranging from 22 to 99. Not all Level I modifiers apply to ophthalmology, however. The most commonly used Level I modifiers are –25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care profession on the same day of the procedure or other service and –50 Bilateral procedure. The second modifier type, Level II, is a two-digit combination — either alpha or alpha numeric. Not all payers recognize Level II modifiers. The most commonly used Level II modifiers in ophthalmology are –RT Right side and –LT Left side.

    When more than one modifier is used, remember to place them in the order of importance, with Level II modifiers following Level I modifiers.

    Recent CMS Changes

    Some recent CMS changes affect the use of modifiers. The Correct Coding Initiative/Medically Unlikely Edits file now dictates that procedure codes with an indication of “1” be billed on only one line. To communicate to the payer that both sides were completed, CMS requires a single line modifier –50 instead of –RT/–LT, with “1” placed in the unit field. This change took effect April 1.

    The new National Correct Coding Initiative edits that took effect July 1 also affect modifiers. Established patient E/M services have recently been bundled with almost all major and minor procedures. You should only use modifiers –25 and –57 to unbundle with extreme caution. As mentioned above, you should only use modifier –25 when the procedure is significant and can be identified as separate from the documentation of the exam.  

    Want to Learn More?

    If you found this helpful, join us in New Orleans for “Making The Most with Modifiers” (event code 361) on Monday, Nov. 18, from 11:30 a.m. to 12:30 p.m. This Annual Meeting course will use some common coding scenarios to help you understand the concepts of modifiers and how to apply them to your practice. Tickets will be included in the Academy Plus course pass, which offers unlimited access to more than 350 sessions.

    Visit the American Academy of Ophthalmic Executives’ website for more information and a full list of course offerings.

    * * *

    About the authors: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE's Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution.