We’re sure the question, “what modifier do I use?”, has popped into your head many times when a patient comes into the office for punctum plugs, an epilation, or an injection. If you’re billing an exam with a minor procedure that has a zero or 10 day global period, modifier -25 is required on the exam IF the exam is unrelated to the procedure.

medicare definition of modifier 25

To get specific, modifier -25 is defined as a significant, separately identifiable evaluation and management (E&M) service by the same physican on the same day of the procedure or other service. The words significant and separately identifiable are important.

The chief complaint for the exam must be significant and separate from the procedure. Does the chief complaint require treatment that, if not addressed during the exam, would require the patient to make another appointment to address it? If yes, modifier -25 would be appropriate to use and an exam would be billable. If the exam was performed to only confirm that need for the minor procedure, then the exam should not be billed.

In the example of cataract surgery, your patient was seen 4 weeks ago for a comprehensive eye exam. During that exam, the decision to move forward with cataract surgery was made. The patient comes back a week later for pre-surgery testing. The exam for this visit is considered part of the preoperative care and included in the reimbursement for cataract surgery, therefore no exam should be billed.

For comprehensive ophthalmology practices, common zero or 10 day global procedures include:

For retina practices, common zero or 10 day global procedures include:

In addition:

  • Modifier -25 always goes on the exam CPT code, not the testing or procedure codes.
  • Modifier -25 can be used on both eye codes and E&M codes.
  • Modifier -25 should not be used on the exam when testing is done on the same day.

Eye Med Management Solutions has years of experience billing for ophthalmology services. If billing has you stumped, read about our results and contact us today to find out how we can help your practice improve your billing operations.

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