Primary Modifiers That Your Ophthalmology Billers Must Know

By Michael Carroll on May 30, 2018

Managing the claim denial process is not only a headache for practices, it will affect your revenue stream. A report from the American Academy of Family Physicians found the average denial rate in the US to be between 5-10% . That means if your practice averages $500,000 per year, you are at risk of losing between $25,000 and $50,000. Even if claims are resubmitted, your practice is likely to experience revenue fluctuations and impacts to cash flow. Think about the staff time involved in researching, correcting and resubmitting claims. Modern Healthcare estimates it costs an average of $118 per claim to recoup those funds. Even if your office just had two denied claims per week, that’s over $12,000 in staff time wasted per year.

Here’s an interesting finding from a 2014 Advisory Board. While two-thirds of denials are recoverable, 90% of them are preventable. How so? One way is by getting modifiers right the first time. Modifiers are an integral part of medical coding. They provide a way for physicians to indicate that a service or procedure has been altered but has not changed so much that it requires a different service or procedure code. Billers must apply modifiers appropriately to avoid claim rejections or denials, ultimately resulting in lost revenue for the practice and possible audits. There are six key modifiers that are critical for all ophthalmology billers to know.

Modifier 24: Unrelated Office Visit in the Post-Op Period

Billers must append modifier 24 to an E/M CPT code when an E/M (evaluation and management) service is performed during a post-op period as an unrelated procedure to that earlier surgery. In other words, this modifier applies if a physician sees or treats a patient for an unrelated issue during the post-op period. Modifier 24 still applies even if a different physician within the same practice is seeing patients for their partner. E/M services can include an examination, medical decision making, counseling, coordination of care, identifying the nature of the problem presented and simply the physician’s time. Having a physician that understands these components and a biller that uses modifier 24 along with referencing the E/M code to the correct unrelated diagnosis on the claim will ensure you are paid for the work that was actually performed. Being familiar with E/M coding prevents undercoding and yields a higher rate of paid claims.

Modifier 25: Office Visit Within 24-72 Hours of Minor Surgery

Modifier 25 is similar to 24 except it refers to a significant, separately identifiable E/M service performed during an office visit within 24 to 72 hours of minor surgery. For example, a patient comes in for follow-up care after cataract surgery. The physician identifies a foreign body during the exam, performs an evaluation and removes it. This E/M service would be reported using modifier 25. The key here, however, is “minor” procedure. CPT does not differentiate between major and minor. However, CMS does and most payers follow their example. “Minor” is any procedure with what CMS defines as a 10-day global period. “Simple” refers to procedures with a zero global period. As we’ll discuss next, “major” refers to procedures with a 90-day global period. These require a completely different modifier.

Modifier 57: Office Visit Within 24-72 Hours of Major Surgery

Modifier 57 applies when the biller wants to alert the payer that an E/M service was performed the day of or within 72 hours of a major surgical procedure. This modifier lets the payer know the surgery was deemed an emergency, so the bill for the E/M service that determined the emergency is not bundled with the surgery payment. Both the E/M with modifier 57 and the surgery should be reported separately and a separate payment should be received for each.

Modifier 58: Staged or Related Procedure or Service During the Post-Op Period

Modifier 58 refers to a “staged or related procedure or service by the same physician (or partner) during the post-op period.” It should be documented if the procedure was planned, more extensive than the original procedure or therapy for the original procedure. Modifier 58 would also apply if the patient is undergoing staged procedures. For example, if a lesser surgery is followed by greater ones or vice versa. Another instance that requires modifier 58 would be if the subsequent procedure was required because the original procedure did not produce the desired outcome. Is something being done to finish what was started during the first procedure such as the injection of medication? If so, modifier 58 is likely appropriate.

Modifier 78: Related Procedure in Post-Op Period

Modifier 78 is defined as an “unplanned return to the operating/procedure room by the same physician (or partner) for a related procedure during the post-op period.” Note the procedure is unplanned and the patient must be returning to the operating or procedure room. Modifier 78 would be appropriate if there were complications from the original surgery that required another procedure. The subsequent surgery must be related to the original, but not planned.

Modifier 79: Unrelated Procedure in the Post-Op Period

Modifier 79 would include an unrelated procedure or service during the post-op period. It must be completely unrelated to the original surgery. For example, if a patient underwent surgery to repair a detached retina, but then had an eye injury that required surgery. The second surgery is totally unrelated and modifier 79 must be used. Note that the diagnosis codes for the original and subsequent surgeries must also be different. Billers must also use 79 in conjunction with modifiers 24 and 25 if the physician is also billing for an E/M service.

If the definitions of these modifiers sound repetitive, it’s because they are. Each modifier is similar with subtle, but critical, distinctions. Think of CPT modifiers like modifiers in the English language. They provide the who, what, when, where and how of a situation. Modifiers help tell the insurer whether multiple procedures were performed, why they were necessary, where they were performed and how many surgeons participated. Providing all that information accurately will speed up your claims process.

Proper documentation and a well-trained biller will ensure your practice gets it right the first time, preserving your revenue stream and protecting your practice from audits. This can be a very complicated process for your in-house staff to manage on their own. In order to make your coding as error-free as possible, it is often helpful to get external help from ophthalmology billing experts like the team at Agnite Health LLC, an affiliate of Advantage Administration, Inc. As one happy client stated, “They are extremely diligent in not letting charges or questionable diagnostic codes slip through the cracks. The communication between their staff and our office is phenomenal! Their services have been cost effective for us and we could not be happier that we transitioned to outside billing.”

To discuss how our services could greatly benefit your practice, contact us today.