ED Coding and Reimbursement Alert

A patient with a foreign body in her left eye reports to the ED. The ED physician removes the FB and sends the patient home.

This might look like a simple coding scenario, but there's more to reporting ocular foreign body removal (FBR) than meets the eye. When coding for these encounters, zoom in on three details:

- the wound's depth

- the FB's location

- the instrumentation.

Read on for more information on coding eye FBRs.

ED physicians will typically treat two types of eye FBRs: conjunctival and corneal. On conjunctival removals, coders need to check if the FB was superficial or embedded, says Pamela McKinley, RHIT, coder at Medical Accounts Services in Frederick, Md.

When the ED physician removes a superficial FB from the patient's conjunctiva, report 65205 (Removal of foreign body, external eye; conjunctival superficial) for the service. For embedded conjunctival FBRs, choose 65210 (- conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating).

The differences: "A superficial FB is exposed to the surface and generally easily moved with a cotton swab," says David Gibson, DO, a practicing optometrist in Texas. To remove a superficial FB, the ED physician might use a swab, tweezers or an instrument called a "golf spud" (because it looks like a tiny golf club), he says.

"Embedded FBs extend into the conjunctiva," Gibson says. The physician will likely use a needle or spud to dislodge the FB, and the spud or tweezers to capture it. "The deeper the FB is, the more likely you-ll need a needle to dislodge it," he says.

Example: A patient complaining of odd sensations in his right eye reports to the ED. The patient says that he was within a few feet of an exploding light bulb earlier that day. On the patient's conjunctiva/conjunctival sac, the ED physician finds a tiny shard of glass, which he grabs and removes using tweezers.

This is an example of a superficial FB, McKinley says. On the claim, report the following:

- 65205 for the FBR

- 930.1 (Foreign body in conjunctival sac) linked to 65205 to represent the FB

- E914 (Foreign body accidentally entering eye and adnexa) linked to 65205 to represent the cause of the injury.

E/M alert: Most ED presentations for FBR will also result in a separately reportable E/M service. If you do code for a separate E/M in this scenario, be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show it is a separate service.

When the ED physician removes a patient's corneal FBR, you-ll need to rely on a different set of codes, Gibson says.

If the ED physician removes the FBR without a slit lamp, report 65220 (- corneal, without slit lamp). Represent corneal FBR removals with a slit lamp with 65222 ( - corneal, with slit lamp).

"The physician must be very careful not to damage the eye if the patient has an FB in his cornea. A slit lamp provides a beam of light (for guidance) and magnifies the FB," McKinley says.

So if the physician is having trouble visualizing the FB for removal, he may use a slit lamp. On your corneal FBR claims, be sure to check for slit lamp use before coding.

Example: A patient with a sore left eye reports to the ED. The physician examines the area, finding several paint chips in the cornea. The physician is able to see two paint chips but is not convinced that the patient has only two FBs. She then uses a slit lamp to visualize the cornea, at which point she finds another small paint chip. The ED physician removes the three paint chips.

Because the physician decided to use the slit lamp to check for further particulate, you should report this service with 65222.

If a patient requires removal of both a conjunctival and corneal FB from the same eye, choose codes for each service. But don't be surprised if the carrier reduces payment for one of the removals, Gibson says.

"You would code the corneal FBR and the conjunctival FBR as normal, but you will probably get a multiple-surgery reduction of fees depending on the carrier," he says. "But bill each code for the full amount, and let the carrier reduce them if it wants."

Other coders report that the use of modifier 51 (Multiple procedures) might speed the claims process with certain payers. That's what McKinley does when coding these types of FBR encounters.

Best bet: Some payers might want to see modifier 51 on claims in which the physician removes FBs from different sections of the same eye; others will just make the multiple-surgery reduction when they receive the claim. If you are unsure of the payer's policies on this issue, check your contract before coding.

Example: A welder with swelling in his left eye reports to the ED. The ED physician finds metal flakes over the patient's conjunctiva/conjunctival sac and cornea, though none of it is embedded. The physician removes two conjunctival flakes with tweezers, then uses a slit lamp and needle to remove a flake from the cornea.

On the claim, you should report the following:

- 65222 for the corneal FBR with slit lamp.

- 930.0 (Corneal foreign body) linked to 65222 to represent the corneal FB

- 65205 for removal of the conjunctival FBR

- 930.1 to linked 65205 to represent the patient's conjunctival FB.

Also, link modifier 51 to 65205 to represent the separate nature of the FBRs -- if the carrier requires it.