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Use modifiers correctly to manage coding and reimbursement process better


Misused modifiers can lead to auditing and billing nightmares for ophthalmic practices. One of the biggest problems is the misuse of Modifier 24 for an unrelated office visit with the same physician during the postoperative period.

Duncanville, TX-Misused modifiers can lead to auditing and billing nightmares for ophthalmic practices, according to E. Ann Rose, president and owner of Duncanville, TX-based Rose & Associates Health Care Consultants.

Modifier 24

One of the biggest problems Rose said she sees is the misuse of Modifier 24 for an unrelated office visit with the same physician during the postoperative period. The key word, she said, is "unrelated." Modifier 24 can be used only for office visits unrelated to the initial procedure. She used the example of doing a glaucoma exam follow-up during a scheduled postoperative visit following cataract surgery.

She also warned against using Modifier 24 for office visits related to surgery complications. Using the cataract surgery example, she said physicians can bill for endopthalmitis-a known complication-treatment if it required a trip back to the operating room, but the physician cannot bill for the office visit.

Second eye surgery exams

Billing for second eye surgery exams is an issue that trips up many practices. Medicare quit paying for second eye surgery exams a long time ago, Rose said, adding that the watchdog for Medicare funds-the Health and Human Services Office of Inspector General-is the "700-pound gorilla" and makes sure the money Medicare spends is on medical claims.

In an audit of practices for which Rose's company consults, she found that patients who presented with operative cataracts in both eyes had visual acuity tests in both eyes, met the lifestyle impairment, and underwent surgery on one eye. Three weeks later, the physicians brought the patients back and went through the same exam, noting the patient retained the lifestyle complaint and consented to going forward with surgery on the second eye. The problem, Rose said, is that second exam is not billable.

A twist occurs if, at the initial visit, only one operable cataract is detected. If a patient returns for a preoperative visit within 89 days of the first exam and an operable cataract is now found in the second eye, that exam is billable because it was not addressed in the first visit. An exam done on the second eye after 90 days also is billable because the preoperative visit is good for 90 days.

Modifiers 25 and 59

Modifier 25 also is a big issue in most practices and involves a significant, separately identifiable exam on the day of surgery. To bill for an exam, the physician must do something above and beyond the surgery.

"Don't use [Modifier 25] with an office visit if no minor surgeries are performed," Rose said.

She said that her other pet peeve is Modifier 59, a highly audited modifier that only is to be used for distinct procedures on a different anatomic site on the day of surgery. The procedure must be completely separate from the scheduled surgery and should not be used with regularity.


Billing for consultations can be tricky as well. The Centers for Medicare & Medicaid Services made a clarification last year regarding consultations, defining a consult as when a referring doctor asks another qualified practitioner for advice, an opinion, recommendation, direction, or counsel about a particular problem. The consulting physician must have expertise in a specific area beyond the referring physician's knowledge.

Rose said an audit will look to see whether the information from that consultant was used in evaluating or treating a patient. It's important for the doctor requesting the consult, as well as the consulting doctor, to have documentation in their records.

A consult done between doctors in a group practice requires a progress note, an order in a medical record, or a specific written request for consultation. An outside referral should be a specific written request. In either case, a notation must be made in the patient's actual medical chart.

"A letter of report and findings must be furnished," Rose said. "The entry can be in the common medical record, or it can be a separate report. If you're using the medical record and the consultant puts the findings in the chart, give it back to the referring doctor so he or she can initial and sign it. Then you have proof that the referring doctor got proof of findings."

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