Coding Corner: Test Yourself: Would You Append Modifier -25?

These 3 common optometry scenarios clear up when you can -- and can't -- separately report E/Ms.

When a minor procedure requires additional up-front work, you may be entitled to additional reimbursement - if you have the necessary documentation to append modifier -25 to a separate E/M service.
 
Many private carriers -- unlike most Medicare carriers -- will reimburse for minor procedures and office visits separately with the correct coding and sufficient documentation, says Janine George, office manager for Mallinger & Eger Optometric Associates in Pittsburgh.

The next time your optometrist inserts a punctual plug -- or performs another minor procedure, such as a foreign-body removal -- reference these scenarios to determine whether the carrier should reimburse you for the office visit in addition to the minor procedure, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.
Punctal Plugs
Code the procedure with an eye/lid modifier and the office visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). A patient reports dry, itchy eyes and generalized pain. The optometrist performs a complete eye exam -- separate from the procedure -- to rule out other causes, and he diagnoses dry eyes. He places collagen punctual plugs in the two lower puncta to see if this resolves the problem.

Report 68761 (Closure of the lacrimal punctum; by plug, each) on two lines and append -E2 (Lower left, eyelid) and -E4 (Lower right, eyelid), plus modifier -51 (Multiple procedures) to denote the lids. For example, you would report 68761-E2, 68761-51-E4. Link 375.15 (Other disorders of lacrimal gland; tear film insufficiency, unspecified) to the punctual plug closure codes. Also report the appropriate-level E/M service with modifier -25 and link it to 379.91 (Pain in or around eye).

Code the procedure alone. The same patient returns for a follow-up visit in three weeks and reports great improvement following the punctual plug placement. The optometrist replaces the temporary plugs with permanent silicone ones. Report the surgical procedure again, as above, and link it to 375.15 for the dry-eye syndrome. You should not separately report an E/M service when the service was an "integral and preoperative" part of the plug placement.
Foreign-Body Removal
One of the trickiest examples of using modifier -25 is for an office visit with a foreign-body removal.

Many optometrists perform an exam, identify the foreign body and attempt to remove it that same patient encounter. The issue becomes one of documentation, Duran says. The optometrist must document the history, exam and medical decision-making first and then do a dated entry for the procedure.

But when [...]