Coding and Billing

The Right Way to Use 11 Common Modifiers in Coding

By Mark K. Davis, OD

Doctor Wearing White Coat Working On Laptop In Office

June 21, 2023

If you have been coding for a while, you know we frequently use modifiers, some more than others. For a complete list of modifiers, consult the back side of the front cover of the CPT manual. I am going to discuss the most common ones we use in optometry and give examples of each.

24 – Unrelated Evaluation and Management service by the same physician or other qualified healthcare professional during a post-operative period.

Example: A patient had cataract surgery and you are assuming the 90-day post-operative care. All is going well, but toward the end of the period the patient comes to your office for an allergic conjunctivitis and you need to treat it. You would code 92XXX or 99XXX with a 24 modifier.

25 – Significantly, separately identifiable Evaluation and Management service by the same physician or other qualified healthcare professional on the same day of the procedure or other services.

This is the most commonly misused modifier. It is applied to the E/M or ophthalmology code, NOT the surgical code.

Example: It is used if the patient is coming in for one diagnosis already known (glaucoma F/U) and mentions something unrelated (FB sensation) and you note trichiasis and need to epilate lashes. It is NOT for something as definitive such as …“I was grinding metal in the garage yesterday and …” or “The wind was blowing hard and I think something blew into my eye…”, etc. It has become the target of auditors.

Here is what the Office of the Inspector General has stated:

“We will determine whether the provider used the modifier -25 appropriately. In general, a provider should NOT bill evaluation and management codes on the same day as a procedure or other services unless the evaluation and management  service is unrelated to the procedure or service”–

26 – Professional component

Example: If you do not have an OCT and you refer to another optometrist to have the scan performed, but you want to interpret the results yourself. They bill for the technical component (TC) and you bill for the professional component: 92133-26

50 – Bilateral procedure

Example: If by chance the patient was shoeing a horse (King Ranch, Texas), was not wearing his safety glasses (of course) and had metal foreign bodies in both eyes, you would code 65222-50. You would also enter twice the normal fee for the procedure. Let Medicare reduce the second procedure by 50 percent.

51 – Multiple surgical procedures the same day, during the same surgical session

Example: A patient was hammering on his swamp boat (again without safety glasses, Beaumont, Texas; Louisiana is not the only state with swamp people) and a piece of fiberglass went into his  eye. You had treated him before for trichiasis on the same eye. Upon slit lamp examination, you note he indeed has a foreign body in his lower conjunctiva, but also his cornea was abraded from the eyelashes that have grown back. If you do not epilate the lashes at the same time as the foreign body removal, he will think you did not get all the debris out. You would code: 65205 – RT (right eye) and 67820-RT-51

52 – Reduced services; under certain circumstances a service or procedure is partially reduced or eliminated at the provider’s discretion.

Example: You take fundus photos (92250) of a diabetic patient that is also monocular (patient has an ocular prosthesis in one eye). The coding would be 92250-52.

Note: Many special diagnostic tests are paid the same whether they are unilateral or bilateral. Take, for example, visual fields and scanning laser ophthalmic imaging (OCT). Both say “unilateral or bilateral” in the CPT manual, indicating you will receive the same payment whether you test one or both eyes. However, under external ocular photography (92285) or fundus photography (92250), neither have the above statement.

55 – Post-operative management only by another physician.

This has been a hot button issue lately with a big settlement in East Texas by an ophthalmology group for anti-kickback charges to induce optometrists to refer cataract surgeries. Click HERE to read more about that.

Post-operative care should be on a case-by-case basis and NOT a blanket agreement with the ophthalmologist. Always do what’s best for the patient. If you are going to provide post-operative care for the patient and they agree, the coding would be as follows: 66984-55-RT or LT 90 days extracapsular cataract removal with insertion of intraocular prosthesis

59 – Distinct procedural service and is used to identify procedures and services that are not normally reported together. The 59 modifier should NOT be appended to an E/M service.

I have seen the 59 modifier used to circumvent the NCCI edit that disallows performing fundus photos and OCTs on the same day. This is fraudulent. Click HERE for an in-depth explanation of how and when to use the 59 modifier.

79 – Unrelated surgical procedure or service by the same physician or other qualified healthcare professional during post-operative period of the original procedure by the same physician.

Example: Patient had cataract surgery and is seeing you for the 90-day post-operative care. Toward the end of the 90-day period, the patient comes in complaining of foreign body sensation in the operated eye. You note trichiasis and epilate the offending lash(es). You would code the visit as: 67820–79-RT or LT.

If you are doing telehealth or telemedicine exams (92XXX or 99XXX) then you should use the following modifiers to let the carrier know that the service provided was not in-person, but via a virtual office visit:

93 – Must be appended to applicable exam codes indicating to Medicare Part B that the exam was performed via audio only telemedicine.

95 – Must be appended to applicable exam codes indicating to Medicare Part B that the exam was performed as telemedicine services.

Other modifiers that I am sure you are familiar with are as follows:

RT – right eye

LT – left eye

E1 – left upper eyelid (Medicare)

E2 – left lower eyelid (Medicare)

E3 – right upper eyelid (Medicare)

E4 – right lower eyelid (Medicare)

You would use the E1-E4 modifiers most often when coding for punctual plugs. Most of the time, we insert plugs only in the lower two punctum. The coding would be: 68761-50-E2-E4

I believe these are the most common modifiers we use in optometry. Keep this article handy for reference in some of the more rare situations you may encounter.

Mark K. Davis, OD, is a Therapeutic Optometrist and Optometric Glaucoma Specialist, Diplomate, American Board of Optometry, Adjunct Assistant Professor, University of Houston College of Optometry and Chief of Optometry, 147th Medical Group. He is Lt Col, Texas Air National Guard, Ellington Field JRB, Houston, Texas.

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