Article Date: 12/1/2009

Make the Most of Modifiers
coding strategies

Make the Most of Modifiers

BY CLARKE D. NEWMAN, OD, FAAO

Next year I will join Dr. Gary Gerber in The Business of Contact Lenses column to discuss other aspects of contact lens practice management in addition to coding. But before we leave the Coding Strategies column behind, I thought we would take one more look at ways we can use the coding process to get our well-deserved dollars.

One method we can employ to improve our reimbursements is to use modifiers. Modifiers are two-digit alphanumeric codes that provide additional information to carriers about the claims that we are making.

Rights and Lefts

First, let's take a look at the −RT and −LT modifiers. You need to be able to tell the carrier that you are billing for service on each eye and not just billing twice for the right eye.

The same holds true for the El, E2, E3, and E4 codes. The first two are left eye and the second two are right eye. Odds are upper lid and evens are lower lid. So, E2 is the "Lower left, eyelid." Again, these codes inform the carrier that you have done a separate procedure on each eyelid and that you are not billing twice for the same thing.

Going Above and Beyond

Next, let's consider the −22 modifier, which is for "Increased Procedural Services." A particular code contemplates a particular level of time, complexity, and risk for a given service. When you need to perform that service, but for some reason it is more complex or requires more time, then you can modify a code by adding the −22 modifier.

This modifier cannot be applied to the Evaluation and Management Services because these services have multiple levels, and if the situation goes beyond the scope of Level 2, then Level 3 should cover it.

However, for codes that have only a single level, such as the 923 lx codes, we sometimes need to bill for a higher level of service. For example, the 92310 code does not contemplate the prescribing of a toric GP corneal lens. So, if you are prescribing a bitoric lens, then you might consider using the −22 modifier.

When you do use this modifier, you need to justify it in a letter that supports the claim of "increased intensity, time, difficulty of procedure, severity of patient's condition, physical or mental effort required." You also have to tell the carrier what you expect in terms of a reimbursement. The carrier is under no obligation to give you any additional money if you don't specify how much. The carrier may still refuse, in which case you can appeal.

Separate Services

The last code that you should know is the −25 modifier. This code is "Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service." This modifier should be used to ensure that the additional services are not considered inclusive of the examination. For example, an E/M service might not get paid if you also bill for a foreign body removal unless you code the E/M service with the −25 modifier. Carriers will always pay the lower of the two when they can get away with it.

While the preamble to the 923 lx codes specifically excludes the examination, which is usually enough to get both the exam and the contact lens services paid, you might want to add the −25 modifier to the examination service. Of course, you have to use E/M services for this rather than the ophthalmological services. CLS


Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, Optometric medicine and refractive surgery. He is also a consultant or advisor to B&L



Contact Lens Spectrum, Issue: December 2009