Examination performed the same day as argon laser trabeculoplasty

At a follow-up exam, a surgeon decides to perform ALT on a glaucoma patient the same day. Is the office visit billable?

Issue: April 1, 2004

ByE. Ann Rose

Issue

A patient presents for a 3-month glaucoma check and states that she frequently forgets to use glaucoma drops. The patient’s IOP is chronically at 22 mm Hg, which is above the target pressure of 12 mm Hg. She is on maximum medication, but is unable to comply with using the drops. After a complete examination, the physician determines that she would benefit from laser surgery because she has difficulty complying with the use of the glaucoma medications. The patient agrees and is taken to the laser room for an argon laser trabeculoplasty.

Is the visit billable when a surgical procedure is performed the same day?

An office visit on the same day as a minor surgery (zero- or 10-day global fee period) is included in the payment for the surgery, unless a significant, separately identifiable service also is performed that requires the use of the 25 modifier.

With the global fee period for ALT (code 65855) reduced from 90 days to 10 days, it is considered a “minor” surgical procedure. As such, any examination performed on the same day must be documented as a separately identifiable examination in order to justify a separate bill.

Because the physician did not determine until the end of the examination that surgery was needed, the 25 modifier would be appropriate. Had the patient presented for the ALT, and the physician examined only the angles and performed an IOP check, the visit would not have been separately billable.