Exam on the day of a minor procedure

Some exams can be billed with a modifier, but some cannot.

Your established patient with glaucoma is not doing well with medications, so another kind of treatment is necessary. During today’s exam, you recommend laser trabeculoplasty as an alternative. After informed consent, you laser the right eye; the left eye is not operated pending results of the first laser procedure. Glaucoma medications are prescribed for the left eye. The patient is asked to return in 2 weeks.

Is this visit billable in addition to the laser trabeculoplasty? If so, how?

Effective Jan. 1, 2002, laser trabeculoplasty (CPT 65855) has a 10-day postoperative period. Previously, the postop period was 90 days. This change effectively makes laser trabeculoplasty a minor procedure according to Medicare. Minor surgical procedures include the visit on the day of surgery in the global surgery package unless there is a separate and identifiable reason for the visit.

CPT defines modifier –25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” It indicates that the patient’s condition required an additional evaluation and management (E/M) service beyond the usual preoperative care provided for the procedure or service. CPT adds that “this modifier is not used to report an E/M service that resulted in a decision to perform surgery.”

The CPT definition of modifier –25 specifically states, “Different diagnoses are not required for reporting of the E/M services on the same date.” So in this case, both eyes have glaucoma and require evaluation while only one is operated today. This case illustrates a separately identifiable exam that is reimbursable in addition to the procedure because the physician had to cope with more than one occurrence of the same problem (ie, glaucoma in each eye). Modifier –25 would be used with the visit. Use of modifier –25 makes full reimbursement of the office visit or consultation and the minor procedure possible. Without it, the exam may be considered preoperative and not paid at all.

If the exam had uncovered more than one problem, it is appropriate to use different diagnoses for the office visit and minor surgery. Modifier –25 would be used with the exam and not the surgery.

If the only purpose of the exam is preoperative care, then a claim for an office visit with modifier –25 would not be appropriate. For example, your patient was seen 3 weeks ago for a comprehensive eye examination. At that time, you made the decision to perform laser trabeculoplasty. She presents today for the procedure. The exam today would be considered preoperative care and included in the reimbursement for the laser trabeculoplasty.

Excessive use of this modifier will garner unwanted attention. The Office of Inspector General’s 2005 work plan identified modifier –25 for continued scrutiny. The OIG seeks to verify that modifier –25 is applied appropriately. Without an unrelated diagnosis, most office visits will not meet the modifier –25 definition. The same day exam is frequently nothing but preoperative work. In some cases, such as this one, the same diagnosis may support both an office visit and a minor procedure on the same day.