CPT Modifier 59 for Optometrists: 6 Ways to Avoid Audit

Highlights

• 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.
• Use optometry-specific coding software to avoid denials and audits.
• Other billing tips include performing internal audits, attending webinars, and bringing in a coding professional for advice.

For optometrists, modifier 59 denotes that a procedure or service provided on the same day is separate from other services. It indicates that each procedure or service is independent and should be evaluated for reimbursement separately.

Misuse of modifier 59 can lead to compliance issues and insurance audits. According to the Office of Inspector General (OIG), about 40% of code pairs submitted with billing modifier 59 are inaccurate. As a result, thousands of optometrists risk compliance penalties and reimbursement issues.

We’ve outlined six optometry billing tips to improve accuracy and adherence to regulations for modifier 59.

CPT Modifier 59 for Optometry Billing

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.

For example, when performing an eye exam, if you notice signs that reveal a need for a glaucoma diagnostic test—and both the exam and test are done on the same day—you can use modifier 59 to show that these procedures are separate.

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..

6 Strategies to Avoid Modifier 59 Code Audits

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. Train Staff Regularly

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 an optometry EHR software that automatically scans and flags procedures that may require separate billing and can suggest modifier 59 where appropriate.

A platform with an auto-coding engine can find potential coding mistakes before submitting claims. For example, it can help avoid using modifier 59 instead of modifier 25. This feature can reduce the risk of audits.

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.

4 . Run 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.