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Modifier 25 + Office Visit + Injection = A Changing Audit Environment
By Riva Lee Asbell, Fort Lauderdale, Fla.

Several issues are prompting increased auditing by Medicare contractors/carriers in reference to coding for an office visit in addition to an intravitreal injection by appending modifier 25 to the office visit. And it's important to note that CMS and the OIG are evaluating the coding of office visits with injections in all fields of medicine, not just ophthalmology.

  • Definition of Modifier 25. Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

  • Medical Necessity. Medicare is heavily auditing the co-billing of office visits with injections. For the most part, there is no medical necessity for coding for the office visit since 10% of the global fee of the intravitreal injection is dedicated to preoperative evaluation and is included in the fee for the procedure.

  • Determining Proper Usage. In a recent audio conference by Wisconsin Physician Services (WPS), presenters stated that when using modifier 25, there should be a great amount of additional work not usually performed when deciding whether or not to perform the surgical procedure. The surgery can be neither preplanned nor prescheduled. A different diagnosis during the office visit and minor procedure (intravitreal injections have a 0 day global period and are thus classified as minor procedures) don't qualify the encounter to be paid separately. Auditors will be evaluating the documentation of previous office visit encounters to make sure this isn't standard preoperative examination documentation.

  • WPS Criteria for Appropriate Usage. Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed. In other words, if you remove the work and corresponding documentation for the intravitreal injection from the chart, is there still enough “significant, separately identifiable services” to bill an office visit code — and which one?

  • WPS Criteria for Inappropriate Usage.
        - A physician other than the physician performing the procedure.
        - Documentation shows the amount of work performed is consistent with that normally
          performed with the procedure.
        - The following statements are false:
            I can always use this modifier for a new patient
            I can always use this modifier when I did not plan the procedure
            I can always use this modifier when the diagnoses are different
            I can always use this modifier when the diagnoses are the same

  • When Can an Office Visit Be Billed? You can see this has become a risky business. You probably may bill an office visit if the patient has new symptoms in the contralateral eye that warrant an examination or if you're managing a problem unrelated to the choroidal neovascularization in the same eye. In these instances, the documentation should be able to stand on its own and be in addition to any documentation for evaluation and treatment of the wet macular degeneration.

  • What Level of Office Visit Is Acceptable? Many practices are using comprehensive eye code (92014) with all intravitreal injections. There's no medical necessity on frequent intervals for this level or for the required elements. In the event a new problem is found in the other eye, it would be an intermediate eye code (92012) or the appropriate E/M code. New patient visits may warrant higher levels of codes.

  • Billing Department and Computer Program Issues. If coders are used in your practice/department, make sure they're not automatically adding office visits/modifiers and the automatic addition of modifier 25 isn't built into the billing program (either manually or mechanically).

Reference: Modifier 25 Fact Sheet
WPS Medicare link: http://www.wpsmedicare.com/part_b/resources/modifiers/modifier-25.shtml

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