ED Coding and Reimbursement Alert

CPT sports codes for both conjunctival and corneal foreign-body removals

If a patient reports to the ED with a foreign body in her eye and your physician performs a foreign-body removal, the coder must discover the type of removal, the location of the FB, and the depth of FB penetration before selecting a CPT code.

Why? Code choice for eye FBRs depends heavily on these three factors. Further, coders should remember to use the proper diagnosis codes on these claims to ensure success. Read on for some expert tips on filing clear and concise eye FBR claims.

Know What Constitutes an -Embedded- FBR

Two main types of eye FBRs are performed in the ED: FBR from the conjunctiva and FBR from the cornea.
 
When your physician removes a conjunctival FB, check the notes to see if the FB was superficial or embedded, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.
 
If the physician removes a superficial conjunctival FB, you should report 65205 (Removal of foreign body, external eye; conjunctival superficial). If she removes an embedded FB from the conjunctiva, use 65210 (... conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating).

How can I tell? A superficial FB may also be referred to in op notes as a -loose- FB. -This type of FB would be one lying just on top of the conjunctiva [and] can easily be removed with a moistened cotton-tipped swab,- Linzer says.

Conversely, -embedded FBs sit in the conjunctiva itself but have not penetrated the anterior chamber,- Linzer says. Physicians may be able to remove embedded FBs with a moistened swab, -but sometimes the FBs will need to be scraped out with a swab or needle,- he says.

Example: A construction worker reports to the ED with a swollen and puffy right eye. The physician examines the patient's eye and sees specks of debris atop the patient's conjunctival sac. She removes the debris using a cotton swab.

On the claim, you should:

- report 65205 for the FBR.
- attach ICD-9 code 930.1 (Foreign body in conjunctival sac) to 65205 to prove medical necessity for the procedure.

Different Code Set Governs Corneal FBRs

The CPT book also contains codes for corneal FBRs. When the physician removes an FB from the cornea, you-ll need to check the op notes for the method of removal before you choose a code, Linzer says.

If the ED physician removes an FB from a patient without using a slit lamp, report 65220 (... corneal, without slit lamp). When the doctor needs to use a slit lamp for the FBR, report 65222 (... corneal, with slit lamp) instead.

Example: A patient reports to the ED complaining of pain in his left eye. The physician examines the patient and discovers that his cornea has an FB, which he promptly removes without the aid of a slit lamp. On the claim, you should:

- report 65220 for the FBR.
- link ICD-9 code 930.0 (Corneal foreign body) to 65220 to prove medical necessity for the procedure.

Code 2 FBRs in Different Parts of the Same Eye

Coding for a single eye FBR may seem clear enough, but what happens when the physician removes FBs from different parts of the same eye?

You should be able to report both of the removals, says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif.

Consider this example, courtesy of Linzer:

A patient reports to the ED, saying he was injured while removing plaster molding from a wall. The patient says the molding shattered and threw plaster into his face and eyes. After irrigation, the exam shows residual plaster in the left eye. Some of the plaster is superficial over the conjunctiva and over the cornea, and some is embedded in the conjunctivae.

After preparing the eye and using a slit lamp, the physician removes all the FBs with a moistened cotton-tipped swab. The patient is placed on antibiotic ointment and referred to an ophthalmologist for follow-up.

In this instance, you may be able to report two codes, depending on the insurer. On the claim, you should:

- report 65222 for the corneal FBR.
- link ICD-9 code 930.0 to 65222 to represent the injury that prompted the service.
- report 65205 for the conjunctival FBR.
- link ICD-9 code 930.1 to 65205 to represent the injury that prompted the service.

Documentation is vital to the claim: -I would definitely send along documentation- clarifying that the FBs were in different parts of the eye, says Deena Happel, CPC, CCS-P, CMA, coder and accounts manager for Lifetime Eyecare in Geneseo, Ill.

That way, the insurer is less likely to deny your claim for multiple FBRs in the same eye.

Best Bet: Contact Insurer Before Filing Eye FBRs

Although the ED physician removed two separate FBs from the same eye in the above scenario, payers won't always reimburse for both procedures.
 
Some will pay for only one removal procedure on the same eye. To maximize the profitability of your claim, report 65222 first because it has the higher relative value units, Linzer says.
 
And some insurers that will pay for both procedures might require you to append modifier 51 (Multiple procedures) to 65205 to show that the physician performed more than one related procedure.

If you don't know an insurer's particular rules on reporting eye FBRs, make sure you find out how it wants you to file the claim before you commence coding.