CODING Q&A

Office Visit/Surgery Modifier: An Often-Confusing Combination

Information provided by Riva Lee Asbell

Recently, I've been receiving a number of questions regarding the tricky area of office visits and under what circumstances they can be tied to modifiers. There are strict limits to modifier use. They are not to be applied loosely.

Modifiers are placed on office visit codes basically for three reasons in Medicare coding: (1) modifier 24 is used to engender payment for the office visit when the patient is in the global period; (2) modifier 25 is used to engender payment for the office visit when there is a significantly separate office visit and the patient is in the global period of a minor procedure (Medicare definition: 0 or 10 day global period); (3) modifier 57 is placed when you want to indicate within a 24-hour period that this is the initial determination for major surgery (Medicare definition: 90-day global period). All of these are under scrutiny by the OIG (Office of the Inspector General) and their usage is being audited.

The reason for scrutiny of modifiers 24 and 25 rests in the inherent definition of a global fee. The global surgical fee is composed of three parts: 10% is dedicated to payment for the preoperative evaluation; 70% to 80% is dedicated to the intraoperative portion of the reimbursement; and 20% of the payment is for postoperative management during the global period.

Q. A patient comes in during the postoperative period of repair of a retinal tear using cryotherapy and complains of new flashes or floaters. Can I bill for this visit?

A. No, you cannot bill for the visit. Note that 20% to 30% of the surgical fee (depending on the CPT code) is dedicated to postoperative management. The symptoms could be related to the original condition or a complication of the procedure.

In this instance you cannot use modifier 24 since it is related, and you cannot use modifier 25 since there is no significant amount of work that is unrelated to the original surgery and that would define the encounter as being outside of the global surgery fee.

Q. Could you review the Medicare policy for coding for office visits when performed at the same session as intravitreal injections? The physician always examines the patient. Are we not entitled to be paid for this? We are hearing conflicting information about use of modifier 25 in this scenario. Please clarify.

A. 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.

In a recent audio conference given by Wisconsin Physician Services, the presenters stated that when modifier 25 is used there should be a great amount of additional work not usually performed when deciding to do the surgical procedure. The surgery can neither be preplanned nor prescheduled. A different diagnosis on the office visit and minor procedure (intravitreal injections have a zero-day global period and are thus classified as minor procedures) does not qualify the encounter to be paid separately. Auditors will be looking at previous office visit encounters to make sure this is not standard preoperative examination documentation.

Medicare has been putting a lot of emphasis on billing office visits with injections and is reviewing the office visits to ascertain there was medical necessity.

Q. We are a three-physician retina practice and cover for each other for postoperative examinations. If one of us, who was not the surgeon, finds a related complication, such as a redetachment, can we then bill for the office visit since it is a different provider? Would we need a modifier?

A. No, you cannot bill for the visit. If the patient had never been seen by your practice and came in for a postoperative visit then it would be a new patient to you and you could code for the visit; however, if the patient is established to the practice then it cannot be billed. RP

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