Part 5 filing 3 rd party claims
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Part 5 Filing 3 rd Party Claims. Addressing: CPT Code Modifiers and When to Use Them. Disclaimers. This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.

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Part 5 Filing 3 rd Party Claims

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Part 5Filing 3rd Party Claims


CPT Code Modifiers and When to Use Them


This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.

To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free.

It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.


• The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services.

• The Nebraska Optometric Association, and its presenters, agents, consultants and staff makeno representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

Coding the Services You Provided

  • Must correctly code the level of care provided

  • Practitioner is ultimately responsible for correct coding

  • Under-codingis as incorrect as over-coding

BOTTOM CMS-1500 Service & Materials Supplied

Exam Coding Modifiers

Modifier 24

  • Unrelated Evaluation & Management Service by the Same Physician During a Postoperative Period.


  • Example: GLC follow-up exam and fields during cataract post-op period.

    • Cataracts 90 days

    • Punctal plugs 10 days

    • Foreign body 0 days


Modifier 25

  • Significant, Separately Identifiable Evaluation & Management Service by the Same Physician on the Day of a procedure


  • Example: Eyelash abrasion detected requiring epilation during a GLC follow-up exam.

    • Use on E&M (99000) code;

    • Documentation for E&M should be separate in record from procedure (each dated & initialed)

      • Separately identifiable entry (different page?)

      • with separate signature

Modifier TC

Technical Component

Some codes can be broken down into aprofessional component and a technical component

  • Professional Componentis done by the doctor

  • Technical Componentis done by a technician

  • No need to break down if both doctor and technician are present when the service is provided. (Possible exception: HPSA)

  • Use breakdown if technician is testing when patient’s own doctor is not present (but there must be a doctor [associate] on the premises.)

  • Modifier TC

    Technical Component

    • Example: technician performing 92083-TC while patient’s own OD is not on the premises

    • Cannot charge Medicare if no doctors are on the premises

    OD and OMD codes that qualify

    Sensorimotor Exam 92060TC

    Orthoptic/Pleoptic 92065TC

    Visual Fields 92081,2,3TC

    Scanning Laser 92135TC

    Fundus Photos 92250TC

    Color Vision 92283TC

    Dark Adaptation 92284TC

    External Photography 92285TC

    Modifier 26

    • Professional Component


    • Example: Doctor’s evaluation of 92083-26 results done the day after technician performed fields (while a different doctor was on the premises).

    Modifier 32

    • Mandated Service


    • Example: driver license exam

    • Not covered by Insurer…patient responsible

    Modifier 50

    • Bilateral Procedure


    • Some services are paid as binocular tests, some as monocular tests

    • If a test is paid as monocular, but you do both eyes, the the 50 modifier is used (with units of 1).

    Modifier 50

    • Bilateral Procedure


    • To determine whether a procedure is bilateral, go to

      • Start Search ->

      • Accept ->

      • Click ‘Payment Policy Indicators’

      • Click ‘Single HCPCS code’

      • Enter Code you are inquiring about

      • Select ‘All modifiers’

      • Submit ->

      • Scroll Look at “Bilt Surg” column

        • 0 means bill each eye separately – bilateral does not apply

        • 1 means paid 100%, 50%, 25% for 1st, 2nd, 3rd unit, respectively

        • 2 means bill once for both eyes

        • 3 means bill each eye separately

    Modifier 51

    • Multiple Procedures


    • Example: multiple (four) foreign bodies in one eye.

    • With four FBs in one eye

      • First FB filed without a modifer, 65222

      • Balance would be filed with 51 modifer –65222-51 , and units of 3 in the units column in this case.

    • Reimbursement diminishes with 51s

    • Medicare does not recommend using modifier 51, but simply increasing “units” instead (65222 with units of 4)


    65222 1 $ 1


    65222 51 1 3x$ 3

    65222 1 4x $ 4

    Reimbursement: 100%, 50%, 25%, 25% …

    Modifier 52

    • Reduced Service


    • Some services are paid as binocular tests, some as monocular tests

    • If a test is paid as binocular, but you do only one eye, the the 52 modifier could be used.

    Modifier 53

    • Discontinued Procedure


    • Example: Discontinued punctal plug insertion during the process because patient became ill.

    Modifier 54

    • Surgical Care Only


    • Indicates post-op care done by another provider

    • Example: Cataract surgery – used by surgeon only

    Modifier 55

    • Postoperative Management Only


    • Example: cataract post-op care

    • Append to the procedure code that describes the surgical procedure. Example: 66984 RT 55

    • Surgery has a 10 or 90-day postoperative period.

    • The claim must show the date of surgery as the date of service.

    • Indicate the date care assumed and date relinquished in Item 19 of the CMS-1500 claim form or the electronic equivalent.

    Surgeon’s name

    Surgeons NPI

    Date assumed care; date relinquished care



    01012009 68984 RT 55 2

    Date of surgery

    Modifier 59

    • • Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under these circumstances.


    • Example: OCT and retinal photos on same day (OCT for GLC, photos for AMD.) Normally denied when claimed together

      • Documentation indicates two separate procedures performed on the same day by the same physician

      • Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)

      • Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in Correct Coding Initiative (CCI) edits.

      • Use Modifier 59 when there is NO other appropriate modifier.

    Modifier GA

    • Used to indicate patient has signed an Advanced Beneficiary Notice (ABN)


    • Used when it is expected Medicare will deny payment for the item as not reasonable and necessary.

    • To collect fee from patient must have ABN signed by the beneficiary on file.

    New ABN Required November 1st

    release date of 03/11 printed in lower left hand corner

    Modifier GA

    • In the ABN’s “reason” box, the provider should state why Medicare will most likely not cover the item:

      • Medicare will probably not cover this item due to your particular diagnosis or circumstance

    • Medicare paperwork to patient, and your Remittance Advice, will then come back with patient responsible for payment.

    Modifier GZ

    • The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient.

    • This will result in claim payment denial, and the patient can NOT be held responsible for payment (provider is out the fee).

    Modifier GW

    • Used for Hospice Patient’s Claims for services not related to the hospice patient’s terminal condition.

    • Otherwise Hospice Patient claims can be denied.

    Modifier GY

    • Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit).

    • It is filed at the request of the patient or to instigate subsequent payment by another insurer.

    • Example: refraction 92015GY.

    Modifier KX [Used for Durable Medical Equipment]

    • Item is covered under some circumstances (if ordered by a physician**).

    • In this case it was ordered by the physician and is medically necessary.

    • You must document why in the patient’s record.

    • **Note: ODs are categorized as physicians under Medicare

    Modifier EY [Used for Durable Medical Equipment]

    • Item is covered under some circumstances (if ordered by a physician**).

    • In this case it was NOT ordered by the physician and is not medically necessary.

    • Patient preference item

    • Patient responsible for payment with this modifier

    • **Note: ODs are categorized as physicians under Medicare

    Thank You for Listening

    We hope this information has been helpful.

    Thank you for listening!

    See our NOA Website for more 3rd Party Educational Videos.

    3rd Party Services

    Nebraska Optometric Association

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