Photo: courtesy of Scott Moscow, OD
Correct use of -24 and -25 modifiers in optometry practice
By Scott R. Moscow, OD
Sept. 18, 2024
I was recently hired as a billing and coding consultant for a practice. The insurance biller at that practice had two incorrect billing habits that saved the insurance company a lot of money!
The first INCORRECT habit was to never bill an E&M service (92XXX/99XXX) during a surgical procedure’s global period.
The second INCORRECT habit was to only bill a procedure OR E&M service (92XXX/99XXX) on a given day, never both.
In this article, we will discuss the correct use of the -24 Modifier [used to appropriately bill an E&M service (92XXX/99XXX) during a global period] and -25 modifiers [used to appropriately bill an E&M service (92XXX/99XXX) on the same date of service as a procedure] WHEN APPROPRIATE.
A Global Period
A global period (or postoperative period) is period of time starting with a surgical procedure and ending some period of time after the procedure where all exams associated with the surgical procedure are covered by a global fee.
Minor surgical procedures have global periods less than 90 days.
Major surgical procedures have global periods 90 days or more
Minor Surgery (<90 day)
- Amniotic Membrane (65778) = 0 days
- Chalazion Injection (11900) = 10 days
- Conjunctival FB Removal (65210) = 0 days
- Corneal FB Removal (65222) = 0 days
- Dilation of Lacrimal Punctum (68801) = 10 days
- Intravitreal Injection of a Pharmacological Agent (67028) = 0 days
- Photocoagulation to Repair Retinal Detachment (67105) = 10 days
- Probing of Nasolacrimal Duct (68810) = 10 days
- Punctal Plugs (68761) = 10 days
- Subconjunctival Injection (68200) = 0 days
Major Surgeries (≧ 90 day)
- Cataract Surgery (66984) = 90 days
- Enucleation (65103) = 90 days
- Pars Plana Vitrectomy with Removal of ERM (67041) = 90 days
- Repair of Retinal Detachment with Vitrectomy (67108) = 90 days
- Scleral Buckle (67107) = 90 days
- Yag Capsulotomy (66821) = 90 days
Laterality & Eyelid Modifiers
Laterally & eyelid modifiers are added to the procedure code.
Laterality Modifiers
- –RT Right side (used to identify procedures performed on the right side of the body)
- -LT Left side (used to identify procedures performed on the left side of the body)
Eyelid Modifiers
- -E1 = Upper Left, eyelid
- -E2 = Lower Left, eyelid
- -E3 = Upper Right, eyelid
- -E4 = Lower Right, eyelid
Exam Modifiers
Both the -24 and -25 modifiers are added to the E&M service (92XXX/99XXX) code.
Other Articles to Explore
-24 Modifier
- The -24 Modifier is for Unrelated Evaluation and Management Service (92XXX/99XXX) DURING a Postoperative Period.
- Evaluation and Management Service (92XXX/99XXX) must be performed for a reason(s) unrelated to the original procedure.
Documentation:
- A diagnosis independent of the surgical procedure required.
- Exam’s primary chief complaint should be completely independent of the surgical procedure.
Example:
- Two weeks after cataract surgery (during the cataract surgery’s global period), a patient gets hit in the left eye with a rubber band and develops floaters secondary to the injury. You perform a dilated office visit that day (two weeks after surgery) and diagnose a PVD in the left eye.
- Chief Complaint: new floater
- History of Present Illness (HPI)
- Location: Left Eye
- Quality: Stable
- Severity: Moderate
- Duration: 3 hours
- Timing: Intermittent
- Aggravating Factors: Hit in Eye with Rubber Band
- Negative Symptoms: No Flashes of Light; No Veil of Blackness
- History of Present Illness (HPI)
Billing:
- E&M Service (92XXX/99XXX) with -24 Modifier
- Associated Dx 1: H43.812 (Vitreous Degeneration, Left Eye)
-25 Modifier
- The -25 Modifier is used for a Significant, Separately Identifiable Evaluation and Management Service (92XXX/99XXX) on the SAME DAY of the Procedure or Other Service
- The patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.
Note: This modifier is NOT used to report an E/M service that resulted in a decision to perform surgery.
Documentation:
- A diagnosis independent of the surgical procedure required.
- Exam’s Primary Chief Complaint should be completely independent of the surgical procedure performed THAT DAY
Example:
- At a patient’s ARMD OU Check you remove a corneal foreign body OD.
- Chief Complaint: Existing Condition, Dry ARMD
- History of Present Illness (HPI)
- Location: Both Eyes
- Quality: Stable
- Severity: Moderate
- Duration: 2 years
- Timing: Constant
- Relieving Factors: AREDS2 Vitamins
- Aggravating Factors: Smoking Cigarettes
- Signs/Symptoms: Visual Distortion
- History of Present Illness (HPI)
- Secondary Complaint: Ocular Pain
-
- History of Present Illness (HPI)
- Location: Right Eye
- Quality: Worsening
- Severity: Moderate
- Duration: 2 days
- Timing: Constant
- Relieving Factors: Closing Eye
- Aggravating Factors: Something got into eye while cutting the grass
- Signs/Symptoms: Tearing
- History of Present Illness (HPI)
Billing:
- E&M Service (92XXX/99XXX) with -25 Modifier
- Associated Dx 1: H35.3131 (ARMD Dry, Early Stage OU)
- Associated Dx 1: H35.3131 (ARMD Dry, Early Stage OU)
- 65222(Corneal FB Removal) with -RT Modifier
- Associated Dx 2: T15.01XA (Corneal Foreign Body OD)
Scott R. Moscow, OD, is the Clinical Director of Roswell Eye Clinic in Roswell, Ga. To contact him: scott@roswelleyeclinic.com
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
