Clearing up modifier confusion
3 Takeaways
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Written by the AOA’s Coding & Reimbursement Committee.
Excerpted from page 48 of the Summer 2024 edition of AOA Focus.
In October 2023, the AOA published information to educate members on the appropriate use and documentation for modifier -25. However, confusion among doctors remains regarding the proper use of modifiers with descriptions similar to that of modifier -25 (modifiers -24, -59 and -79). Understanding the differences between them, and the appropriate use of each, will aid any doctor of optometry's reimbursement and audit survival.
Modifier -24
Unrelated evaluation and management (E/M) service by the same physician or other qualified health care professional during a postoperative period.
Modifier -24 is used when an unrelated E/M service is necessary during any 10- or 90-day postoperative period. It is used for any underlying condition but is not used for complications from the procedure. The procedure diagnosis can only be used for this E/M if the problem impacts a different anatomical site.
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EXAMPLE: Patient returns for an examination without any ocular complaints. Left eyelid trichiasis is found and corrected. The modifier -25 is appended to the E/M. The examination was not related to the trichiasis or the epilation performed on the same day as the eye exam, thus the exam is a significant, separately identifiable E/M service (Code 92014-25 Z01.00 plus 67820 H02.055). |
Modifier -25
Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Per the Centers for Medicare & Medicaid Services (CMS), new patient E/M codes are excluded from any global surgery package edit and do not require a modifier for reimbursement.
Modifier -25 is appended to any established patient E/M code (99211-99215, 92012, 92014, etc.) that is concurrent to a procedure having a global period of 0 or 10 days. Proper documentation must satisfy the criteria for the E/M service being reported (example below).
The National Correct Coding Initiative (NCCI) typically considers any E/M service provided on the day of a procedure to be bundled, and the reimbursement rates already include the pre- and postoperative care. (Other payer policies may differ.)
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EXAMPLE: Patient returns for an examination without any ocular complaints. Left eyelid trichiasis is found and corrected. The modifier -25 is appended to the E/M. The examination was not related to the trichiasis or the epilation performed on the same day as the eye exam, thus the exam is a significant, separately identifiable E/M service (Code 92014-25 Z01.00 plus 67820 H02.055). |
Modifier -59
Distinct procedural service.
CMS has published a great deal on the appropriate use of modifier -59. To ensure understanding, providers should carefully review CMS, Medicare carrier and private insurance plan information of modifier –59 use. This modifier is applied to one procedure when two procedures, not normally reported together, are performed on the same day, and is not used with E/M services. Documentation must support these procedures being performed together.
The NCCI edits provide information on when and if modifier -59 can be applied. Both procedure codes should be reviewed in NCCI to determine when modifier -59 is allowed. (CMS alternatives to -59: XE, XS, XP, XU.)
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EXAMPLE 1: 92134 (ocular coherence tomography, retina) and 92133 (ocular coherence tomography, optic nerve) are both performed, modifier –59 applied to 92133. Modifier -59 is not allowed and 92133 is denied because NCCI edits indicate these two procedures cannot be billed together under any circumstances. |
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EXAMPLE 2: 92134 (ocular coherence tomography, retina) and 92250 (fundus photography) are both performed, modifier -59 is applied to 92250. The documentation indicates 92134 was performed because of macular degeneration, right eye, while 92250 was performed because of a suspicious choroidal nevus in the left eye. Both are allowed if modifier -59 is used. |
Modifier -79
Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
Modifier -79 is applied when a second procedure is performed during the postoperative
period of another procedure. It is always the first modifier reported because it is considered a pricing modifier. A new postoperative period begins when the -79 modifier is used. Modifier -79 does not apply to any procedure or surgery that has a global
designation of “XXX” in the Medicare Physician’s Fee Schedule database. Optometrists are relatively familiar with the application of the -79 modifier because it is often required when a second cataract surgery occurs during the postoperative period of the first cataract procedure.
Access the #AskAOA “Proper Documentation and Why It Matters” course on EyeLearn, the AOA’s Professional Development Hub.
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