The Connection OnlineSM

April 2011

April 2011

Ophthalmological E&M services denial changes

Effective July 1, we will begin denying the following CPT and Health Care Procedure Coding System (HCPCS) codes when billed with ophthalmology surgical procedures for the same patient, same provider, same date of service, using our Same Day edit denial:

  • CPT 92012 Ophthalmological services; medical examination and evaluation; with initiation or continuation of diagnostic and treatment program; intermediate; established patient
  • CPT 92014 Ophthalmological services; medical examination and evaluation; with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
  • CPT 92015 Determination of refractive state
  • HCPCS S0621 Routine ophthalmological examination including refraction; established patient

We currently have assigned code pairs found in our Correct Code Editor (CCE) that deny these CPT and HCPCS codes when billed for the same patient, same provider, same date of service as an ophthalmological surgical procedure. However, when bypass Modifiers -25 and -57 are used, they do not bypass the established CCE code pairs. This creates unnecessary denials and subsequent claim appeals. Our new process will allow the bypass modifiers to function correctly.

Information on our Same Day edits is located in the Coding Toolkit.


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