Did you know you might be expected to return money that insurance

or third-party payers paid you? It’s not uncommon for optometry and
ophthalmology practices to frequently misuse billing modifiers. When
insurance and third-party payers determine you incorrectly used a
medical billing modifier on a claim, this can become a costly mistake.

Modifiers are added to the Healthcare Common Procedure Coding

System (HCPCS) or Current Procedural Terminology (CPT®) codes
to provide additional information necessary for processing a claim,
such as identifying why a doctor or other qualified healthcare
professional provided a specific service and procedure.

To make it more complicated, payer rules for how to use modifiers vary
with specific HCPCS and CPT® billing codes. Not all modifiers can be
used with HCPCS or CPT® codes. It’s also critical that you keep up with
Local Coverage Determinations (LCD) to ensure you are coding
claims correctly.

Unfortunately, misusing medical billing modifiers can trigger an audit

that can lead to hefty fines—audits can go back many years. Medicare
audit fines might be as high as $10,000 for each occurrence. This
means every time you bill a modifier on a claim incorrectly, you may
have to pay $10,000 for each occurrence. That adds up quickly.

Here are some red flags to look out for when billing with a few common
modifiers. Knowing when and when not to use a modifier maximizes
reimbursements and prevents denials and potential audits.

What are HCPCS and CPT Codes?

HCPCS codes are standardized five-character, alpha-numeric code
sets used for billing Medicare and Medicaid patients that correspond to
services, procedures, and equipment not covered by CPT® codes. The
 Centers for Medicare and Medicaid Services (CMS) monitors HCPCS
billing codes.

CPT codes are published by the American Medical Association® and

consist of three types or categories of five-character codes and two-
character modifiers to describe any changes to the procedure.

Medical Billing Modifier 24

Modifier 24 Definition: “Unrelated evaluation and management
(E/M) service by the same physician or other qualified health care
professional during a postoperative period.”

Modifier 24 is used when a doctor provides co-management

services. It is only used to append to E/M codes. It’s important to keep
accurate records that document the specific E/M service the patient
received for the treatment of the underlying condition that was not
related to the surgical procedure during the postoperative period.

For example, if a patient has cataract surgery and experiences

complications in the eye not operated on—or if the patient suffers
complications in the operated eye and it’s located in the region of the
eye that was not impacted by the surgery—you can append modifier
24.

Never use modifier 24 if:

 The surgical complication is considered part of the global surgery

package.
 The patient requires pain management related to the surgical
procedure.
 The patient is admitted to a skilled nursing facility for a condition
related to the surgery.
 Follow-up E/M visits are related to the patient’s recovery following
surgery.
 The postoperative period (10- or 90-day global period) is no longer
valid. A global period consists of the time before, during, and after a
surgical period that covers the patient care for the particular
procedure.
 Services were rendered on the same day as the procedure (refer to
modifier 25).

What is the Global Period? A global period consists of the time

before, during, and after a surgical period that covers the patient care
for the particular procedure.

Medical Billing Modifier 25

Modifier 25 Definition: “Significant, separately identifiable
evaluation and management (E/M) service by the same physician on
the same day of the procedure or other service.”

Modifier 25 is used when you perform a procedure—and a significantly

unrelated and separately identifiable E/M service—during the same
session or the same day.

To support the elements of an E/M service that is above and beyond

what a provider would perform for the procedure that same day, you
must submit clear documentation showing why the procedure was
necessary, and link modifier 25 to the appropriate E/M CPT® code.
 While you do not need to use two different diagnosis codes, you must
document both the E/M service and procedure.

For example, for some patients, you may need to report modifier 25
when “removing a foreign body or closing a punctum with a punctal
plug.” However, many E/M services are often provided as a standard
part of performing surgical services.

NEVER use Modifier 25 to:

 Append to surgical codes, medical procedures, or diagnostic tests and

procedures as payers will deny it as an invalid modifier combination.
 Append to an E/M code that is explicitly used for a new patient and is
not a procedure or other service code.
 Bill for a doctor other than the doctor or other qualified healthcare
provider performing the procedure.
 Bill with a procedure or service with no global fee period (0, 10-day, or
90-day global period).

Medical Billing Modifier 55

Modifier 55 Definition: “Post-operative management care only.”

Modifier 55 is used to identify when a doctor performs the

postoperative management and another doctor performs the surgical
care only procedure (modifier 54).

According to the CMS Medical Learning Network Global Surgery

Booklet, “The physician, other than the surgeon, who furnishes post-
operative management services, bills with modifier 55. Use modifier 55
with the CPT procedure code for global periods of 10-days or 90-days.
This modifier is not appropriate for assistant-at-surgery services or for
ASC facility fees.”
 CMS requires that doctors keep copies of the written transfer
agreement in the patient’s medical record. You must also provide “at
least one service before billing for any part of the post-operative care.”

During a recent aging claims report analysis with a Fast Pay Health
client, we noticed a pattern of denials for postoperative claims that
were consistently getting denied for missing information. By
processing the claims with the Assumed Care date, Relinquished Care
date, Surgeon (as referring provider) and modifier 55, the practice is
now receiving full payments.

Never submit Modifier 55 with:

 CPT® codes that have a 0 days global period

 E/M services
 Global surgical split modifiers 54 and 56
 Modifier 80 (assistant surgeon)
 CPT® 99024 (postoperative follow-up visit)

Medical Billing Modifier 59

Modifier 59 Definition: “Distinct Procedural Service.”

Modifier 59 is one of the most used modifiers. You should only use
modifier 59 if you do not have a more appropriate modifier to describe
the relationship between two procedure codes. Modifier 59 identifies
procedures/services that are not normally reported together.

Modifier 59 is used if the same doctor or qualified healthcare

professional performed an unrelated procedure on the same patient on
the same day the doctor performed the office visit. For example, some
optometry offices use modifier 59 to get paid for both OCT/GDX and
fundus photography in the same visit.
 Your documentation “must support a different session, different
procedure or surgery, different site or organ system, separate
incision/excision, separate lesion, or separate injury (or area of injury in
extensive injuries) not ordinarily encountered or performed on the
same day by the same individual.”

Though the National Correct Coding Initiative (NCCI) edits allow

the use of modifier 59, determining if it is appropriate to use can be
tricky.

Never attach modifier 59 to an E/M service. Depending on the local

policy, if the tests are necessary due to two separately identifiable
conditions, you may be able to link the appropriate diagnosis code to
each CPT® code and add modifier 59 to the second procedure. To
report a separate and distinct E/M service with a non-E/M service
performed on the same date, check to see if modifier 25 is appropriate.

CMS uses four sub-modifiers that replace modifier 59:

 Modifier XE – “Separate Encounter: A service that is distinct because

it occurred during a separate encounter.” Only use this to describe
separate encounters on the same date of service.
 Modifier XS – “Separate Structure: A service that is distinct because it
was performed on a separate organ/structure.”
 Modifier XP – “Separate Practitioner: A service that is distinct because
it was performed by a different practitioner.”
 Modifier XU – “Unusual Non-Overlapping Service: The use of a service
that is distinct because it does not overlap usual components of the
main service.”

Medical Billing Modifier 79

Modifier 79 Definition: “Unrelated procedure or service during a
post-operative period.”

Modifier 79 is used for unrelated procedures provided by the same

physician or other qualified health care professional during the
postoperative period.

For example, if the patient has a complex cataract surgery (66982) on

the right eye on March 1 and the doctor performs the same surgery on
the patient’s left eye on April 1, the surgery on the left eye should be
reported as 66982-79-LT.

It’s not uncommon to get postoperative claims paid incorrectly or not

at all, especially when the surgery of a second eye takes place during
the global period for the surgery that was performed on the first eye.
When you use modifier 79 correctly, this allows the claim for the
second eye to be paid. Remember, each eye’s global period
(postoperative) runs independently of the other.

Never apply modifier 79 to office visits (see modifier 24) and only
append to other unrelated surgery or procedures with a 90-day global
period.
 How to Use Informational Eyelid
Modifiers
Common ophthalmic procedures for Level II HCPCS Medicare claims
that require eyelid modifiers include Epilation (67820-67805), Punctal
plug procedures (68760-68761), and Chalazion excision (67800-
67805).

RT (right eye) and LT (left eye), and eyelid modifiers E1-E4 are used for
the CPT® codes listed above to provide additional information about
the services provided, such as anatomical site.

 E1 Modifier: A service was performed on the upper left eyelid

 E2 Modifier: A service was performed on the lower left eyelid
 E3 Modifier: A service was performed on the upper right eyelid
 E4 Modifier: A service was performed on the lower right eyelid

Medical Billing Best Practices

The financial health of any eye care practice depends on complete
ophthalmology and optometry billing solutions and revenue cycle
management. It’s critical to pay close attention to using modifiers
correctly, accurately documenting patient records and physician notes,
and ensuring claims are not under or over-coded.

While all optometric practices will experience claim rejections and

denials, at Fast Pay Health, we know the ins and outs of insurance and
third-party payers best. Knowing how to prevent rejections and
denials in the first place is the best “cleaning solution” to receiving
revenue quicker.

Fast Pay Health billing consultants are experts at making sure

medical claims are clean and free from errors before we submit them.
Coders are well versed in CPT® and ICD-10 coding and billing with
code modifiers.

Request a free practice analysis today and start reaping the

benefits of fewer denied claims and faster payments.