Ask the Coding Experts: Modifier 24 and 25 usage

January 20, 2016
Report reveals some doctors of optometry bill claims with modifiers 24 and 25 at a higher rate than other eye care providers.

Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.

From the November/December 2015 edition of AOA Focus, pages 46-47.

In September 2015, the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services released a report on billing for "ophthalmology services."

For the past several years, the OIG has focused on these services because of their significant costs under the Medicare program. In 2012, Medicare paid $6.7 billion to 44,960 providers for eye care services that screen for, diagnose, evaluate, or treat two prominent eye conditions: wet age-related macular degeneration and cataracts.

The OIG report sought to determine the extent to which ophthalmology services are vulnerable to fraud, waste and/or abuse. It is important to be aware of the findings of this report as the broad category of "ophthalmology services" includes many of the procedures provided by doctors of optometry, and the report includes some specific data on billing by doctors of optometry.

Overall, the OIG report found that most eye care physicians did not exhibit questionable billing practices. However, the report did provide some data indicating that certain doctors of optometry are billing claims with modifiers 24 and 25 at a higher rate than other eye care providers. While higher than average reporting does not necessarily indicate fraud or abuse, the report findings provide an opportune time to review appropriate use of these modifiers.

Here are key points to remember when reporting modifier 24 and modifier 25:

Modifier 24

  • For doctors of optometry, modifier 24 is most often used when the doctor is providing co-management services.
  • Modifier 24 is defined as an "unrelated evaluation and management service by same physician during postoperative period." This means if a patient has surgery and has a condition that requires an evaluation that is completely separate from anything related to the surgery, an evaluation and management (E/M) service would be reported and modifier 24 would be appended.
  • Modifier 24 is often reported by doctors of optometry in cases in which the patient experiences an eye problem in the eye that was not operated on, or when the patient has an eye problem in the operated eye that is located in the region of the eye that was not impacted by the surgery.
  • This modifier should only be used with E/M services.
  • It is critical that documentation should include the specific reason why the visit that occurred during the postoperative period was not related to the surgery.

Modifier 25

  • Modifier 25 is officially defined as "a significant evaluation and management service by same physician on date of global procedure." This means if E/M services are provided that exceed what is normally involved in preparing a patient for a procedure and the standard follow-up services directly following a procedure, then an E/M service should be reported along with modifier 25.
  • Reporting modifier 25 may be necessary in certain cases when removing a foreign body or closing a punctum with a punctal plug.
  • It's important to recognize that many E/M services are provided as a standard part of performing surgical services. For example, during a foreign body removal, obtaining the patient's ocular and general medical history; performing an external exam; evaluating distance vision; and a slit lamp examination would all be standard procedures performed prior to the foreign body removal.
  • However, it is possible for additional E/M services to be necessary when performing surgical services. For example, if a patient presented for treatment of glaucoma and in the course of treating the patient the doctor identified a foreign body, the evaluation for glaucoma and the foreign body removal would be reported. The E/M would be reported with modifier 25.
  • Modifier 25 should only be used when reporting E/M services.
  • Documentation must reflect the necessity of the E/M service.
  • Doctors of optometry should be aware that an E/M service that is provided on the day of procedure with a global fee period will only be reimbursed if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative work of the procedure.
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