Dr. Wolfe says foreign body removal like this requires specific coding protocols for proper documentation and reimbursement.
Proper billing for foreign body removal: Understanding the -25 modifier
By Christopher Wolfe, OD, FAAO, Dipl. ABO
July 31, 2024
Foreign body removal is a common procedure that requires precise coding for accurate billing and reimbursement.
Navigating the intricacies of medical billing can be daunting, and the use of appropriate modifiers is essential to ensure compliance and proper compensation.
This article aims to delve deeper into the proper way to code foreign body removal, highlighting the use of the -25 modifier and providing practical guidance for optometrists.
THE Question
“What is the proper way to code a foreign body removal? Years ago, we billed an office visit and a separate code for the procedure. Later, we switched to only billing one or the other.”
Do it the correct way:
The debate over the correct use of modifiers in medical billing is ongoing. As a general comment about modifiers, it can be helpful to think about modifiers as an EXCEPTION to the rule rather than THE RULE.
If you find yourself consistently modifying codes, be sure you are doing it correctly rather than just doing it whichever way you think will get you paid more. This debate can exist when we mistake “getting paid” with “coding correctly.”
While some practitioners advocate for a method of billing both an office visit and a procedure code using a -25 modifier, this approach is not aligned with the intended use of the -25 modifier in conjunction with surgical codes. Typically, it is more appropriate to choose either the foreign body (FB) removal code or the office visit code, not both.
Understanding the -25 Modifier
The -25 modifier is crucial in the realm of medical billing, particularly for procedures requiring separate evaluation and management (E/M) services. Here’s a breakdown of its definition and proper usage:
Definition: The -25 modifier is used to signify a significant, separately identifiable E/M service provided by the same physician on the same day as another procedure. This modifier is added to the E/M service code to indicate that the service was distinct from the procedure performed.
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Use Case: Consider a scenario where a patient comes in for a glaucoma evaluation. During the examination, the optometrist discovers a foreign body in the eye and proceeds to remove it.
In this case, both the glaucoma management and the FB removal are necessary. The optometrist would bill a 99214 (let’s assume the patient had documented side effects of treatment and a prostaglandin was continued) for the glaucoma evaluation and management, and 65222 for the foreign body removal.
The -25 modifier is added to the 99214 code to denote that the E/M service is separately identifiable from the procedure performed on the same day. The key point here is that the medical record also documents the complexity of each and that each were medically necessary during this visit.
Practical Application of the -25 Modifier
Key Points for Using the -25 Modifier:
- Significant and Separate E/M Service: The E/M service must be significant and separately identifiable from the procedure. It should not be part of the usual preoperative and postoperative care associated with the procedure.
- Documentation: Clear and thorough documentation is vital. The medical record should explicitly state why the additional E/M service was necessary, detailing the distinct nature of the evaluation beyond the procedure.
- Same-Day Service: The -25 modifier is used when the E/M service and the procedure occur on the same day.
Additional Example of Proper Coding with the -25 Modifier
- Multiple Conditions: A patient visits the optometrist for a follow-up on dry eye syndrome and also complains of a scratchy sensation. Upon examination, a foreign body is found and removed. Here, the physician would bill a 992XX code for the dry eye management, including a -25 modifier, and 65222 for the foreign body removal.
Conclusion
Proper coding for foreign body removal involves understanding and appropriately applying the -25 modifier. By using either the foreign body removal code or the office visit code and ensuring clear documentation, optometrists can optimize their billing processes. Adhering to these guidelines helps in maintaining compliance and ensuring accurate reimbursement for the services provided.
By mastering these nuances in medical billing, practitioners can focus more on patient care while ensuring their practice’s financial health. Accurate and compliant coding is not just about getting paid; it’s about upholding the integrity and efficiency of the healthcare system.
Christopher Wolfe, OD, FAAO, Dipl. ABO, is the founder of EyeCode Education and the owner of Exclusively Eyecare, a Vision Source practice in Omaha, Neb. To contact him: drmoskweli@gmail.com
