AE May/June 2021 Vol 30 No 3 - 45

Table 1. CPT Codes for Using a -25 Modifier With an Office Visit
CPA Code

Description

67101

Repair of retinal detachment, including drainage
10-days
of subretinal fluid when performed; cryotherapy

67105

Repair of retinal detachment, including
drainage of subretinal fluid when peformed;
photocoagulation

10-days

67028

Intravitreal injection of a pharmacologic agent
(separate procedure)

0-days

67221

Destruction of localized lesion of choroid (e.g.,
choroidal neovascularization); photodynamic
therapy (includes intravenous infusion)

0-days

67227

Destruction of extensive or progressive
retinopathy (e.g., diabetic retinopathy), cryotherapy, diathermy

10-days

67228

Treatment of extensive or
progressive retinopathy (e.g., diabetic retinopathy), photocoagulation

10-days

to schedule a fully dilated
exam, say twice a year, to
evaluate both eyes' health
(absent any necessitating
complaints from the patient)
is reasonable. Ensuring the
chief complaint documentation is supportive and
addresses the reason and
findings for the full exam
is equally important. Build
your case-it does not have
to be verbose, but it should
be supporting.
*	 Was the procedure previously scheduled?
The plan note from the
previous office visit usually
includes when the patient
is to return; any testing
orders, e.g., retinal OCT;
and another injection.
Statements about " possible
injection " do not support the
use of a -25 modifier since

Global Days

the " significant " and " separately identifiable " criteria (see Table 1).
KEEP IN MIND
The changes to E/M codes for 2021
do not change the documentation
requirements for using the -25 modifier. Remember, the -25 modifier is
not a " decision for surgery " modifier,
and the payment is inherent in the
global surgery package. Additionally,
the history and exam elements do
not create medical necessity. The
chief complaint and the documentation supporting the " significant " and
" separately identifiable " instruction
to use the -25 modifier establish the
medical necessity. AE
NOTES

the " decision for surgery " is
an inappropriate use of the
modifier. Furthermore, CMS
states that the decision for
minor procedures is " typically
done immediately before the
service. " 3
*	 Does the physician address
one or more diagnoses that
affect the treatment and
outcome?
Suppose the physician performs a periodic examination
of the complete visual system
to evaluate the eyes' health.
The diagnosis may not differ
from the reason for injection.
However, providing supporting documentation is essential
to establish " significant " and
" separately identifiable. "
Retina practices have several CPT
codes that may necessitate using a
-25 modifier with an office visit when
performed on the same day and meet

1 Current Procedural Terminology
(CPT).  American Medical
Association.  2021.
2 https://www.cms.gov/
outreach-and-education/medicarelearning-network-mln/mlnproducts/
downloads/globallsurgery-icn907166.
pdf " https://www.cms.gov/
outreach-and-education/medicarelearning-network-mln/mlnproducts/
downloads/globallsurgery-icn907166.pdf

"

In my
professional
experience,
most
documentation
fails to contain
a different
reason for the
office visit to
substantiate
using a -25
modifier.

3 https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/
Downloads/clm104c12.pdf " https://
www.cms.gov/Regulations-andGuidance/Guidance/Manuals/
Downloads/clm104c12.pdf

L. Elizabeth Cifers,
MBA, MSW, CHC,
CPC (804-512-1883;
elizabeth@
elizabethcconsulting.
com), is the owner of Elizabeth
Cifers Consulting, LLC, Kill Devil
Hills, N.C.

www.asoa.org // AE

45


https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf https://www.cms.gov/outreach-and-education/medicarelearning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf http://www.asoa.org

AE May/June 2021 Vol 30 No 3

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