ED Coding and Reimbursement Alert

Question: A patient presents to the emergency department (ED) complaining of pain in their right eye with tearing and burning. The patient was working in the yard, mowing and trimming, earlier in the day without protective eye covering. The patient does not use any eye medications. On exam, the ED physician notes the patient’s visual acuity is diminished in the right eye. Intraocular pressures are within normal limits. There is no nystagmus. The right eye is dilated and a slit lamp is brought into position. There is a 2 mm x 2 mm corneal epithelial defect and a very small object, apparently a piece of a leaf, seen with the slit lamp. There is no corneal stromal infiltrate or thinning. The leaf has most likely scraped the cornea, causing a minor abrasion. The ED physician uses a moistened cotton swab to successfully remove what is, as suspected, a small leaf fragment. The physician prescribes antibiotic eye drops for the patient to use at home over the next seven days. If problems persist with the eye, the patient will follow up with their primary care physician (PCP). How should I code this encounter?

Revenue Cycle Insider Subscriber

Answer: Your scenario should rate a foreign body removal (FBR) code for the leaf removal along with a separate emergency department (ED) evaluation and management (E/M) service.

On your claim, report:

• 65222 (Removal of foreign body, external eye; corneal, with slit lamp) for the FBR
• Modifier RT (Right side) appended to 65222 to indicate laterality
• The appropriate E/M code from 99281-99285 (Emergency department visit for the evaluation and management of a patient …)
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to the ED E/M code to show that the FBR and the E/M were significant, separately identifiable services
• T15.01XA (Foreign body in cornea, right eye, initial encounter) appended to 65222 and the ED E/M to represent the patient’s injury
• W60.XXXD (Contact with nonvenomous plant thorns and spines and sharp leaves, subsequent encounter) appended to 65222 and the ED E/M to represent the cause of the patient’s injury

E/M explanation: As with all ED encounters, this was not a planned procedure. Therefore, the ED physician must perform a separate E/M before the encounter to know exactly what is wrong with the patient and how they’re going to address it. Be sure to level the E/M service appropriately according to the encounter notes.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC