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Ophthalmology Coding Alert

Avoid a Modifier -25 Rut for Same-Day E/M Services

Modifier -57 is the better bet for more intensive services If your ophthalmologist provides an evaluation and management service that leads to the decision to perform a major surgery on the same day or the day before, be sure to append modifier -57 to the E/M code. Otherwise, payers could bundle the evaluation into the surgery and deny your practice legitimate compensation by misinterpreting the service as preoperative. 3 Conditions Govern Your -57 Use To append modifier -57 (Decision for surgery), the services the surgeon performs must meet three conditions:

1. The E/M service must occur on the same day of or the day prior to the surgical procedure.

2. The E/M service must have directly led to the surgeon's decision to perform surgery.

3. The surgical procedure following the E/M must have a 90-day global period (that is, it must be a "major surgical procedure"). CPT doesn't have a set time frame for pre- and post-operative services. Medicare, however, directs carriers to "[p]ay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure," according to the Medicare Carriers Manual, section 15501.1. Most private payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Sandra Zarowitz, patient accounts manager at the VMR Institute, a practice specializing in laser therapy and surgery of the vitreous, macula and retina, in Huntington Beach, Calif.

You can also append modifier -57 to the eye examination codes (92002-92014, Ophthalmological services: medical examination and evaluation ...), Zarowitz says.
Experts say: Be on the lookout for laser procedures. Ophthalmologists commonly perform YAG laser capsulotomy (66821), focal laser treatments (67210) and pan-retinal photocoagulation (67228) on the same day as an evaluation. An ophthalmologist typically will not take a patient to an OR or ASC setting on the same day as an evaluation, unless the patient has an urgent retinal condition or injury due to trauma, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

For example: During a consultation, the ophthalmologist determines he needs to repair a detached retina that day. The procedure contains elements of 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling and/or removal of lens by same technique).

Because the detached retina repair is a major procedure, you [...]

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