ED Coding and Reimbursement Alert

Question: A patient with a foreign body in her left eye presents to the ED for treatment. The ED physician performs foreign-body removal (FBR) from the cornea with a slit lamp after conducting a level-three evaluation and management service to check for further injury. How should I report this encounter?

Connecticut Subscriber
 
Answer: You-ll be able to report a pair of CPT codes in this instance -- one for the E/M and one for the FBR. On the claim:

- report 65222 (Removal of foreign body, external eye; corneal, with slit lamp) for the FBR.

- report 99283 (Emergency department visit for the E/M of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity).

- attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99283 to show that the E/M was a significant and separate service from the FBR.

- link 930.0 (Foreign body on external eye; corneal foreign body) to 65222 and 99283 to prove medical necessity for the encounter.

Remember: If your physician performs corneal FBR without a slit lamp, it affects your code choice. If the physician does not use a slit lamp, you should report 65220 (... corneal, without slit lamp) instead of 65222.