coding q & a
Modifiers and Exam Codes
Understand your coding options for one of your most common claims.

By Suzanne Corcoran, C.O.E.

Modifiers play an important role in submitting claims for reimbursement because they provide additional information about a service. However, some modifiers are compatible with exam codes and others aren't.

Q What modifiers may we use with exam codes?

Optometrists use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure) more than any other. It applies when an exam takes place on the same day as a minor procedure (one with zero to 10 days of post-op care). (See Coding Q&A in the February 2003 issue of OM for more detail.)

Q What modifiers should we avoid?

Avoid using modifier -52 (reduced services) for exam codes. Instead choose a lower level of service when you perform a lesser exam. Some optometrists learned to use modifier -52 with exam codes as a way of describing a discounted service. The Medicare Carriers Manual §15501 B(2) states, ". . . CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare doesn't recognize modifier -52 for this purpose."

Medicare and many other payers expect you to bill them for your "usual charge" for a service but you may not bill them more than your usual charge. Medicare determines your usual charge by how much you charge the majority of your patients (>50%) for a particular service. Payers, especially Medicare, could decide that the amount you're submitting to them on your claims is substantially more than your usual charge and lower your allowable amount. For example:

• You charge Medicare and other insurers $100 for a comprehensive exam.
• You charge a cash patient $75 for the same exam.
• Medicare could determine that $75 is your real fee because that's what you usually charge. So instead of paying you 80% of $100, they will pay you 80% of $75. Appending modifier -52 to the code for cash patients doesn't resolve this situation. As a practical matter, pick one fee for all payers and stick with it. Multiple fee schedules are inherently discriminatory and problematic.

Q Is there an alternative?

In eye care, we're accustomed to two sets of CPT codes: E&M codes (992xx) and eye exam codes (920xx). But there's an alternative -- the S-codes, which are:

• S0620 - Routine eye exam, including refraction, new patient
• S0621 - Routine eye exam, including refraction, established patient

Medicare doesn't accept these codes because they don't cover routine eye exams. Many other payers accept or even require them, especially some of the vision plans. When performing a routine exam on a healthy-eyed patient, these codes are a good alternative to the usual CPT codes. They also allow flexibility in your fee schedule and reduce the temptation to apply a double standard or use modifier -52 inappropriately.

Suzanne Corcoran is vice president of Corcoran Consulting Group.  Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.