From the American Academy of Ophthalmology

Services notified the Academy this week that it will resume bundling of global surgical procedures such as CPT 67028 Intravitreal injection and other codes billed with an eye-visit code. The Academy, working with the American Society of Retina Specialists, successfully stopped the edits last fall. They showed evidence that claims were inappropriately being denied, even when correct modifiers were applied. Effective July 1, CMS will resume the edit of CPT 92012 and CPT 92014 with all global surgical codes including zero-, 10- and 90-day procedures. The carriers will not retroactively review claims back to April 1. However, any claims received on or after July 1 with dates of service on or after April 1 will be subject to the edits.

CMS first implemented edits bundling established patient evaluation and management codes, as well as CPT codes 92012 and 92014, into global surgical procedures last July. However, most carriers’ claims-processing systems did not allow modifiers -24, -25, or -57 with the two eye-visit codes.

The notice, sent from the National Correct Coding Initiative (NCCI), the edit contractor for CMS, indicates that effective April 1, the carrier-processing systems will now allow these three modifiers with CPT codes 92012 and 92014. The edits will be designated with a "1," which indicates that an exam may be unbundled when appropriate from the surgical procedure. When an exam is a significantly, separately identifiable service from the procedure performed on the same day, it is appropriate to append modifier -25 at the end of the exam code.

NCCI also highlighted payment policy when using the modifier -25. “For minor surgical procedures (global period of 000 or 010 days), an E&M service is separately reportable on the same day as the procedure only if significant and separately identifiable. An E&M service should not be reported solely for the decision to perform the minor surgical procedure. A significant and separately identifiable E&M service is indicated with modifier -25.” If the patient is only examined to determine the need for an injection in the eye scheduled for treatment, then a visit should not be billed.

Here’s an example of when modifier -25 can be appended with an eye-visit code: a patient who presents for an exam of their left-eye neovascular AMD after receiving an anti-VegF injection one month prior, who reports improved vision in that eye, but now has decreased vision in the right eye with distortion. Examination shows new neovascular AMD in the right eye. Testing confirms neovascular AMD in right eye and the patient receives an injection. Further information about the use of modifier -25 can be found in the Academy’s October 2010 issue of EyeNet.

For more information contact the Academy’s Government Affairs division at 202.737.6662.