Ophthalmology and Optometry Coding Alert

Question: If one of our ophthalmologists sees a patient with a chalazion, and at the time of the visit he decides to remove the chalazion, how should we code for that? What if the ophthalmologist asks the patient to come back another day?

Illinois Subscriber

Answer: If the visit is necessary to determine the necessity of removing the chalazion, you can report an E/M service (99201-99215) along with the chalazion treatment code. Append modifier 25 (Significant, separately  dentifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

If the patient comes back another day, code for the purpose of the chalazion removal procedure on that day, and if the treatment was an injection, such as Kenalog, you should report 11900 (Injection, intralesional; up to and including 7 lesions) for intralesional steroid injection of a hemangioma. You would use this code for up to seven intralesional injections of any kind.

For eight or more lesions, report 11901 (... more than 7 lesions).

Another option: If the ophthalmologist actually excises the chalazion, you should report a surgical excision code. CPT provides three codes for chalazion excisions in the office: 67800 (Excision of chalazion; single), 67801 (... multiple, same lid), and 67805 (... multiple, different lids).