CPT Modifier 59 for Optometrists: 6 Ways to Avoid Audit

optometrist standing next to glass display case


  • Modifier 59 is a CPT code that allows optometrists to bill for separate services performed on the same day. 
  • Modifier 59 is an overused code, making it a high-level risk for audit triggers for CMS and insurers.
  • To help avoid billing issues, take steps like using autocoding software and training your staff on the proper use of modifier 59. 
  • Other billing tips include performing internal audits, attending webinars, and bringing in a coding professional for advice. 
  • RevolutionEHR simplifies the billing process, reducing errors with features like an auto-coding engine and specialist billing team for accurate claims. 

Modifier 59 for optometrists indicates that a procedure or service provided on the same day is separate from other services performed. This modifier helps clarify that each procedure or service is independent and should be considered for reimbursement on its own merit.

Misusing this modifier can cause issues with healthcare billing compliance and prompt an audit. The Office of Inspector General (OIG) has discovered that about 40% of code pairs submitted with billing modifier 59 are inaccurate, which might result in penalties and reimbursement difficulties.

To address this, we’ve outlined six optometry billing tips to improve accuracy and adherence to regulations through the correct application of modifier 59 for optometrists.

Understanding CPT Modifier 59

CPT modifier 59 is an essential code for optometric billing. It signals that a service or procedure is different from others given on the same day. It tells insurance companies that, although services are typically not reported together, they are appropriate under the circumstances.

Take, for instance, performing an eye exam on a patient and observing signs that suggest the need for a glaucoma diagnostic test. If both the examination and the test are conducted on the same day, modifier 59 can be applied to indicate that these procedures are independent of each other.

Using modifier 59 correctly is key to getting your optometry billing right. The correct paperwork and codes can protect your practice from claim rejections and third-party audits. It also confirms that you’re billing separately for different procedures, helping ensure you get paid on time.

6 Ways to Avoid Audit with Correct Use of Modifier 59

Your optometry billing strategies can help you avoid audit triggers for modifier 59. Use the following tips to improve your coding process and reduce your risk of billing mistakes.

1. Provide Comprehensive Documentation

Thorough documentation minimizes the likelihood of an audit for modifier 59. Start by detailing the procedures in patient records and explaining each service and the appropriate code.

Include the specific context for using modifier 59. “Administered 92004 for a comprehensive eye exam. On the same day, performed 92020 for gonioscopy due to suspected glaucoma, necessitating separate evaluations.”

Ensure this information is recorded in the billing software and the patient’s medical chart. Regularly review your documentation practices to ensure that they meet current coding standards and guidelines, keeping detailed notes that justify the use of modifier 59 for each case.

2. Conduct Regular Staff Training

For better compliance with modifier 59, ensure your staff is well-trained and has access to coding resources. Attend webinars or workshops by coding experts to cover the latest billing and coding practice updates. Encourage staff to attend industry events and training sessions focused on optometry billing, specifically those that address the proper use of modifiers.

Organize periodic in-house training sessions where staff can share insights and strategies they’ve learned. Encourage certification and continued medical billing and coding education to ensure your team’s skills are up to date and compliant with current regulations.

3. Use Automated Coding Tools

Use automated coding tools to improve accuracy and efficiency in using modifier 59. Implement an optometry EHR that automatically scans and flags procedures that may require separate billing, suggesting modifier 59 where appropriate. A platform with an auto-coding engine can help identify potential coding issues, like interchanging modifier 59 and modifier 25, before submitting claims, reducing the audit risk.

Ensure the software has regular compliance updates to reflect the latest coding standards and practices — train staff on how to use these tools, including understanding the software’s suggestions.

two optometrists looking at CPT modifier 59 information

4 . Conduct Internal Audits

Regularly check your billing practices to keep audit risks low for modifier 59. Aim to conduct internal audits every six months. Randomly pick a few claims to review, ensuring that modifier 59 is used according to the patient’s medical records and that there’s a good reason for billing procedures separately.

If you find consistent errors, identify their root cause. This can help you see gaps in training or coding information and make changes to correct mistakes and improve billing procedures.

5 . Stay Updated on Policy Changes

The American Medical Association (AMA) publishes annual updates to CPT codes. You must comply with these updates within six months of their effective date.

Regularly check the AMA and the Centers for Medicare & Medicaid Services (CMS) for the latest guidance on new use requirements. Subscribe to updates from these organizations and the American Optometric Association (AOA) to stay informed about CPT code changes relevant to your practice.

6. Get Professional Consultation

Consider consulting with billing specialists or certified coders for guidance on modifier 59. Their expertise can ensure you apply and document it correctly in complex billing scenarios or when you’re unsure.

Make it a habit of regularly consulting with these experts to review and improve your billing practices. This will help you remain compliant and minimize mistakes.

optometrist holding a laptop

RevolutionEHR: Simplifying Coding and Billing

RevolutionEHR, an all-in-one optometry practice management software, streamlines the coding and billing process, enhancing accuracy and efficiency. With RevolutionEHR, you can focus more on patient care and less on administrative tasks with the following features:

  • Automated coding solutions. RevolutionEHR’s auto-coding engine automatically identifies and applies the correct billing modifiers for each service, reducing coding errors and improving billing accuracy.
  • Integrated insurance clearinghouse. RevClear improves the claims process by seamlessly connecting with insurers, ensuring that claims are submitted correctly the first time with appropriate modifiers.
  • Regulatory compliance and reporting features. RevolutionEHR supports your practice with tools like RevAspire, which has detailed reporting capabilities to help maintain complex billing regulatory compliance and prepare you for CMS audits.

RevBilling: Let Us Handle Your Coding and Billing Headaches

RevBilling from RevolutionEHR streamlines your billing process, ensuring faster and more effective payments. This service improves revenue collection and reduces administrative expenses by saving on training and setup costs.

RevBilling provides your practice with its own team of billing specialists who can help boost your bottom line with tailored financial services.

Features and benefits include:

  • Streamlined claims submissions to ensure accuracy and speed
  • Boosted cash flow with quick reimbursement turnarounds
  • Precise ledger reconciliation for accurate financial oversight
  • Guaranteed timely insurance payment postings for immediate financial clarity
  • Detailed follow-up to resolve rejections and denials for better cash flow
  • Cutting-edge analytics for strategic financial planning

Simplify Modifier 59 for Optometrists With RevolutionEHR

Choosing the correct optometry billing software can help avoid errors associated with modifier 59, streamlining its application for quicker and more accurate insurance reimbursements. RevolutionEHR offers a comprehensive solution that supports all aspects of coding and billing for optometry offices, complemented by a dedicated team of specialists to ensure you stay on track.

Schedule a demo today to learn more about how RevolutionEHR can give you the freedom to focus on your patients and give them the high-level care and attention they deserve.

See why revolutionehr gives you freedom to focus.