A Tale of Two Modifiers

One of the most misunderstood and improperly used aspects of billing and coding is modifiers. Modifiers are added to Current Procedural Terminology (CPT) codes to provide the payer with more detailed information about what was done during a procedure or visit without changing the basic definition of the CPT code. Many different modifiers can be used, which may indicate whether a CPT code pertains to one or both eyes, among a multitude of other variations.<

Two of the most used—and misused—modifiers in eye care are -25 and -59. This article discusses the proper use of these two modifiers to ensure your billing and coding is completed correctly and to help you avoid denied claims, audits, and fraud investigations.

MODIFIER -25

Modifier -25 is defined as “significant separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ This modifier may be attached to either the 92xxx ophthalmology codes or the 99xxx evaluation and management (E/M) codes when an additional procedure is performed on the same date of service. For example, if a patient is seen for a routine checkup to assess the effectiveness of their glaucoma medications and a foreign body or dry eye associated with their glaucoma medication is discovered, modifier -25 would be attached to the E/M code, along with the appropriate glaucoma diagnosis code. (In the case of a foreign body, the 65222 removal code would also be billed with the appropriate foreign body code.) Proper documentation in the chief complaint and history of present illness sections of the record should explain that the visit and the procedure are not related for coding purposes.

Be aware that there are circumstances in which the E/M visit code is bundled with the procedure code. For example, if a patient is seen with a chief complaint of foreign body sensation in the eye and a foreign body is found (and is thus the cause of the foreign body sensation complaint), the office visit and foreign body removal are bundled; in this case, you would only bill the 65222 removal procedure code, even if more than one foreign body is found in the eye. Although that is indeed the proper way to bill the foreign body removal, some insurers will incorrectly pay you for both the E/M code with modifier -25 and the 65222 removal code. In the case of a formal audit, the fees received for the E/M portion of the visit would most likely be recouped.

Some providers may mistakenly attach a symptom diagnosis code, such as H57.1x, to the E/M code with modifier -25 and bill the 65222 with the foreign body code as well, thinking that using two different diagnosis codes will result in a higher payment. However, once you find the cause of the symptom, you may only use the foreign body diagnosis code. Providers who knowingly incorrectly use the modifier in this way and receive payment could be accused of insurance fraud. In the event that a cause for the foreign body sensation is not found, a 2024 ICD-10 code should be used: H57.8A (1, 2, or 3, depending on the eye[s] involved), along with the E/M code for the visit.²

Remember, modifier -25 is used only when performing a procedure in addition to the E/M visit and should not be used when the patient undergoes testing, such as OCT or visual fields, on the same date of service.

MODIFIER -59

The other commonly misunderstood modifier is -59, which is used when “necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day.”¹ This modifier is used to “unbundle” services or tests that should not normally be performed on the same date of another service. These prohibitions are noted in the National Correct Coding Initiative (NCCI) edits, which are updated quarterly and are readily available online. The Centers for Medicare and Medicaid Services developed a more detailed description of modifier -59 (see Modifier -59 According to CMS).

In eye care, NCCI edits prohibit performing multiple imaging procedures on the same day. This applies to fundus photos and OCT. Theoretically, you may bill fundus photos and OCT on the same day if each test was completed for different diagnoses. To do so, you would bill each test with a different disease diagnosis code and attach modifier -59 to one of the imaging codes. In most cases, insurers will not pay when modifier -59 is used; however, some will, if it is not used too often. Frequent use may trigger a formal audit, so it is important that the medical record documentation supports the use of modifier -59.

KNOWLEDGE IS POWER

When used appropriately, modifiers -25 and -59 allow eye care providers to perform multiple procedures on the same date of service for their patients. However, using either modifier inappropriately and/or too frequently may increase the risk of a formal audit, which may result in recoupment of payments. In addition, if it is proven that these modifiers were being used inappropriately with the provider’s awareness, the provider may be subject to fraud investigation.

Every provider wants to be paid appropriately for their patient care. However, if you are not knowledgeable on the proper use of codes and their modifiers, you may experience a higher percentage of denied claims that require resubmission, not to mention other, more costly problems. A thorough understanding of these commonly used modifiers will go a long way to help you prevent such problems.