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Modifiers 25 & 57

Tammy Posted Mon 10th of November, 2014 09:17:21 AM

Do you still Modify Eye Codes just like E/M Codes?

SuperCoder Answered Mon 10th of November, 2014 09:40:53 AM

Hi Tammy, thank you for your question. It would depend on the eye code that is being billed and what it is being billed out with. It would not be appropriate to state that all Ophthalmology codes allow for/or need modifier 25 and/or 57.

Tammy Posted Mon 10th of November, 2014 13:17:26 PM

I do understand what your saying, but I don't see the documentation. I was just trying to give my provider some general information regarding this, so what reference material can I give my provider's, so they can code properly their E/M & Eye Codes when they do procedures?

SuperCoder Answered Mon 10th of November, 2014 15:27:25 PM

Please see the information below, this should be helpful in educating your providers:

CCI implements bundles for ophthalmological procedures already covered by global period guidelines.

The newest CCI (Correct Coding Initiative) edits went into effect on July 1, and include more than 14,000 edits that apply to ophthalmologists. CCI 19.2 added almost 293,000 new edits altogether, according to an analysis by Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Focus on E/M Services When Considering New Edits

Digging into the edits is a daunting prospect on the surface, but isn’t so intimidating once you take a closer look.

Here’s why: Virtually every edit associated with opthalmological services includes the same set of approximately 55 E/M codes. E/M services bundled into the procedures include the following sections:

Patient office visits (99202-99205 for new patients or 99212-99215 for established patients)
Initial hospital observation care (99218-99220)
All hospital inpatient E/M services (99221-99239)
All inpatient and outpatient consultation services (99241-99255)
Critical care services (99291 and +99292)
Nursing facility services (99304-99316)
Most domiciliary and home services (99324-99350)
Four codes for care plan oversight services (99374, 99375, 99377, and 99378).

CCI Errors Struck Opthalmology Codes, Too

If ophthalmological evaluations are a big part of your practice’s revenue, you’ve probably been experiencing a level of stress beyond frustration thanks to CCI 19.2, which also bundled 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) and 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) into scores of procedure codes. Fortunately, however, you will be able to recoup the money you lost from those troublesome CCI edits in October.

That’s the word from an Aug. 27 CMS Open Door Forum, in which CMS’s Chris Ritter acknowledged that edits bundling 92012 and 92014 have caused challenges for coders.

“NCCI will be suspending edits beginning Oct. 1, and claims that been denied after July 1 because of the lack of a 25 modifier on either of those two codes can go ahead and be resubmitted after that time,” Ritter said. CMS plans to work on making edits more appropriate for these two E/M codes, she added.

In black and white: You can read an Aug. 20 letter from CCI’s Niles Rosen, MD to the American Academy of Ophthalmology’s Michael Repka, MD confirming the upcoming edit reversal, which the AAO posted on its website at In the letter, CMS admits that even modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) was not allowing legitimate claims to bypass the edit as it should have, which is what led CMS to decide that deleting the edits was the best idea going forward.

Even if your doctor billed correctly in the first place for these services, MACs will not automatically reprocess claims, Ritter stressed. Instead, you will have to resubmit the bill to your MAC after Oct. 1. You should resubmit the claim at that point as if you’re sending the bill for the first time, Ritter clarified—you do not need to send in an appeal.

Tammy Posted Mon 10th of November, 2014 16:47:46 PM

Thank you so much for your help!

SuperCoder Answered Mon 10th of November, 2014 17:28:27 PM

You are very welcome!

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