Internal Medicine Coding Alert

Question: A 75-year-old established patient with cataracts in her right eye reports to the internist with a swollen and red right eye. The internist performs an expanded problem focused history and expanded problem focused exam, and discovers "dust particles" clogging the patient's eyelid and conjunctiva. Using a few saline eye drops, the internist removes the particles, bandages the patient's eye and sends her home. Can I report a foreign body removal (FBR) for this encounter?

Minnesota Subscriber

Answer: This is more likely an E/M service, though you might want to investigate more before deciding. If the encounter is an E/M, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M with 930.1 (Foreign body on external eye; foreign body in conjunctival sac) appended to represent the patient's injury and 366.10 (Senile cataract, unspecified) appended to represent her cataracts.

Rationale: Even though the patient technically had an FB in her eye, the work your internist did really does not qualify the encounter for an FBR.

Coders report either 65205 (Removal of foreign body, external eye; conjunctival superficial) or 65210 (... conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating) for conjunctival FBRs, depending on the location and penetration of the wound. During these encounters, the provider often uses a burr, needle, tweezers, or some other tool to remove the FBs.

Best bet: Check with your payer to see if it will accept 65205 for the amount of work your physician performed in this instance. Saline irrigation is considered an FBR technique, but it typically takes more than just a few drops to wash the eye out.

Also, internists rarely perform these types of procedures; they're more the purview of optometrists and ophthalmologists. So be careful when considering eye FBR codes.