Checking for head trauma is often a sign of separate E/M
Each time the ED physician performs a foreign-body removal (FBR) on a patient's eye, coders should check the notes for evidence of a separate evaluation and management service.
With an eye FBR, the physician may have to examine the patient for other injuries and trauma. When she does, E/M reporting becomes possible, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.
How will I know? On eye FBR claims, the op notes should show you whether the physician provided a separate E/M. You may be able to code for an E/M along with an eye FBR if notes indicate that the ED physician:
- examined the anterior structure of the eye (cornea, anterior chamber).
- checked the papillary reactivity/roundness of the eye.
- visualized the vitreous/posterior chamber.
- tested for tetanus prophylaxis.
- considered administering antibiotics to the patient.
Suppose a patient with an irritated left eye reports to the ED. The physician may check the patient for other signs of injury during the course of an expanded problem- focused exam of the patient's eyes, ears, nose, throat, skin, and neurological systems. After discovering that the above areas are trauma-free, the physician proceeds with a superficial FBR from the conjunctiva.
In this instance, the physician performed an eye FBR and a separate E/M. On the claim, you should:
- report 65205 (Removal of foreign body, external eye; conjunctival superficial) for the FBR.
- report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem- focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M service.
- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99282 to show that the E/M and the eye FBR were significantly separate services.
- include documentation highlighting the physician's actions during the course of the 99282 service.
