Ophthalmology Billing: Help with Modifier 25
I'm hoping someone who does coding/billing in Ophthalmology specifically can help. I've recently had denials from Anthem Medicare Advantage where they are requiring the use of modifier 25 with any E&M or eye code billed along with ophthalmic testing (for example, modifier 25 with E&M when billed with an OCT, visual field, or gonioscopy).
Typically the only time we use modifier 25 is when an unrelated exam is performed on the same day as a minor procedure. In all the years I have been doing this, I've never seen modifier 25 needed on an exam when billed with ophthalmic testing, and at the very least I know Medicare doesn't require it.
Even the Anthem commercial plans are processing our claims with no issue (along with literally every other insurance we bill), it's only Anthem Medicare Advantage plans that are denying our claims for not using modifier 25.
I'm frustrated because my reconsiderations have all been upheld, and of course they do not state why, just simply "our original decision was correct."
I'm not sure how to fight this as I cannot locate anything specifically from CMS or our MAC stating the correct use of modifier 25. I also found an AMA article adding to the confusion by stating that basically ANYTHING billed along side an exam will require the exam to have modifier 25. Maybe that's true outside of Ophthalmology, I honestly don't know since I've only ever done Ophthalmology billing.
Is anyone else experiencing this issue? Any advice? I'm tempted to just rebill the claims with 25, but I also know they're wrong, and being a Medicare Advantage Plan, they should be following Medicare guidelines. Anthem notoriously hates Ophthalmology, or at least I think they do lol. They often treat medical exams billed with eye codes as "vision only" and we frequently have to fight those denials, too.