Awareness : Did You Know? 2015-2016

Did You Know? Weekly Educational Series 39

For the Week of July 4, 2016

Ophthalmology Billing Tips for the use of Modifiers 25 and 57

Case No. 1

An established patient being treated on a treat-and-extend basis for wet age-related macular degeneration (AMD) in the right eye returns for optical coherence tomography (OCT). It is decided that an intravitreal injection will be given in the right eye that day. An exami¬nation is performed prior to the injection, and the OCT performed earlier that day is reviewed. Coding: Modifier 25 should not be used to engender payment for the office visit.

Case No. 2

A new patient is referred as an emergency by a retina specialist for a recent onset of retinal branch vein occlusion in the right eye. There were no other complaints or findings in either eye. The surgeon performs an intravitreal injection of bevacizumab (Avastin, Genentech) in the right eye after examining both of the patient’s eyes. There were no other signifi¬cant ocular findings warranting treatment. Coding: The office visit is included with the procedure.

Case No. 3

An established patient presents for a scheduled intravitreal injection of ranibizumab (Lucentis, Genentech) in the left eye for wet AMD. The patient complains of flashes and floaters in the right eye, accompanied by decreased vision. An inferior retinal detachment is observed in the right eye. Coding: This is a significantly separate condition that is new to the examiner. Use modifier 25 on the office visit.

Case No. 4

A new patient presents with a retinal detachment in the right eye and is scheduled for surgery using pars plana vitrectomy the next day. Coding: Append modifier 57 to the office visit because this is a major surgical procedure and this is the initial determination for surgery.

Case No. 5

A patient is in the global period after repair of tractional retinal detachment in the right eye. He comes in for an emergency examination with sudden loss of the inferior field of vision in his left eye. The patient is scheduled for repair of the newly found retinal detachment in his left eye the next day. Coding: Append modifiers 24 and 57 to the appropriate examination code. Modifier 24 engenders payment in the global period and modifier 57 engenders payment for the initial determination for performing the retinal detachment repair.