Let’s think about how E/M modifiers “work” in Ophthalmology
by Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant
The concept of modifiers and CPT coding is fairly straightforward, however sometimes we add modifiers without thinking about long term consequences and the view from the insurance side of payment. Here are a few basic facts to consider as you append a modifier:
- For Ophthalmology the right and left are critical when dealing with the location of the procedure or service. Even though the ICD 10 coding now identifies the location of a cataract or chalazion or other anomaly, the CPT code still requires the RT or LT. Modifier 50 is for bilateral procedure and only one (1) unit is used.
The RT, LT or modifier 50 are never appended to an E/M code. They may be appended to diagnostic codes (imaging).
- When providing multiple procedures on the same day that are surgical in nature, not testing, there is no “magic modifier” that allows for full payment on all the procedures you perform. The Medicare rule, and the one most insurance programs follow, is that the first procedure is approved at the full fee schedule amount; the second procedure is approved at half or 50 % of the fee schedule amount and all additional procedures that are identified as performed and medically necessary (not part of a bundling edit) are approved at 25% of the fee schedule amount.
The E/M modifiers support the payment of the E/M service with a surgical or diagnostic service as a separate payment and do not impact the payment of the surgical care.
Remember for traditional Medicare the patient is responsible for 20% of the approved charges. For Advantage Plans it may be a set dollar amount for the services provided and for commercial insurance plans it may be a mix of first dollar coverage, amounts applied to a deductible or a set percentage of the approved amount.
- Modifier 25 is a tricky modifier with the purpose of allowing Medicare and commercial insurance plans to pay or allow payment for both an evaluation and management service and a procedure on the same day.
First, this modifier is not required on initial or new patient visits using either the Ophthalmology coding process or the E/M codes.
Modifier 25 may be required when the same provider is also performing specific diagnostic testing on the same day as an E/M or vision service, however not all insurance programs required modifier 25 in these cases.
The definition of Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.
The coding of an E/M on the same day would indicate the documentation supported the E/M service beyond the usual procedure pre and post care and that the assessment for the procedure was significant and documented to support either additional medical or surgical issues impacting the patient care (diabetes, glaucoma, deafness in a vision patient).
If the procedure is scheduled as part of a prior visit or assessment, then normally the service would be coded as the procedure alone.
The use of modifier -25 is normally used for minor procedures that either have zero (0) or ten (10) days as part of their pre, intra and post procedure care process.
- Modifier 24 is used on an E/M service that is unrelated to a major procedure (global service of either 10 or 90 days). This could be a patient who had a procedure on the right eye that now requires and assessment of a problem on the left. The documentation would identify the problem of the unaffected eye (non surgically attended eye). If a procedure is required (foreign body removal) then modifier 24 is appended on the E/M as the first modifier and modifier 25 is appended as the second modifier.
The definition of modifier 24 an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period. Medicare defines same physician as physicians in the same group practice who are of the same specialty.
Modifier -24 cannot be used when one assessed, diagnoses and planned for the second eye at the time of the first eye (cataracts) unless there has been as significant change, issue or process involved in the overall care plan.
Modifier -24 is not used on the same day as a procedure, even if after a procedure has been completed, this would (based on documentation) support the modifier -25)
Modifier -24 only impacts the E/M services, not testing services.
Modifier -24 is never used for post operative complications, infections, suture removal or other components of a minor or major procedure that are considered inclusive of that procedure.
- Modifier 57 is used to report the decision for surgery for certain codes. This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
This modifier is appended to either new or established patient care E/M services when there is a major procedure performed such as a trauma, retinal tear or fracture.
The purpose of the modifier 57 is to allow payment for both the E/M and the surgical procedure and requires that the documentation of the E/M service goes beyond the basic pre operative assessment and plan.
The modifiers appended to E/M services may result in Medicare and insurance programs audits and review of documentation to assure the support of their use. Things that you can do to make sure the modifiers are used correctly would be:
- Education of providers on correct use of each type of modifier and stress the importance of documentation when using the modifiers.
- Routinely self- audit for correct modifier use
- Review diagnoses coding to assure that it supports the modifiers appended.
- review of the coding for the care provided for which they are
Use of modifiers can enhance reimbursement but if used incorrectly raise compliance concerns and the potential for Medicare or Insurance program review.
If you have any questions or need reimbursement assistance, please use this form.