Ophthalmology and Optometry Coding Alert

See these NCCI code bundles clearly.

If you’re feeling hesitant about filing claims for patients with trauma, hypotony, and other sight-threatening conditions, don’t be. By paying close attention to your ICD-10-CM injury choice codes and your CPT^® code bundles, you’ll code even the most complex eye injury scenarios efficiently and accurately.

That’s why we put together this tricky case study for you. To gauge your expertise and boost your coding skills, we’ve added questions for you to answer every step of the way.

Try Your Hand at Coding This Case

History – The patient sustained severe ocular trauma to his right eye while working on machinery, resulting in a corneoscleral laceration with a metallic foreign body. Inspection of the sclera revealed multiple posterior rupture sites. There was a corneoscleral limbal entry site where a large metallic foreign body was situated. The ophthalmologist also noted anterior capsule compromise and clouding of the lens, leading to the decision to perform a pars plana lensectomy.

Question: What ICD-10-CM codes should I report?

Answer: In this scenario, the patient sustained an injury to the right eyeball by a sharp object with a retained foreign body, resulting in an ocular laceration and traumatic cataract. The diagnosis codes for the initial encounter include:

• S05.51xA (Penetrating wound with foreign body of right eyeball, initial encounter)
• H26.101 (Unspecified traumatic cataract, right eye)
• S05.31xA (Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter)
• W31.1xxA (Contact with metalworking machines, initial encounter)

Because the note included enough information on how the metallic foreign body and laceration occurred, you can include an external cause code. Keep in mind, however, that use of these codes is not mandatory for Medicare.

Initial surgery – The physician attempted to remove the metallic foreign body with an 18-gauge magnet; however, removal ultimately required the use of large retinal forceps. Further surgery involved primary open globe repair, pars plana vitrectomy (PPV), pars plana lensectomy, and anterior chamber washout. Cultures were taken; intravitreal antibiotics were injected.

Question: What CPT^® codes do I report for the initial surgical procedures?

Answer: The ophthalmic surgeon performed a non-magnetic extraction of the foreign body in the right eye, so you’d report 65265 (Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction) with modifier RT (Right side) appended.

Then, the provider broke down the lens material and removed it from the eye to treat the cataract; no intraocular lens was inserted. For this, you’d submit 66850 (Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration) with modifiers 51 (Multiple procedures) and RT appended. Following the removal of the ocular foreign body, the surgeon repaired the injury in the cornea and sclera, coded as 65280 (Repair of laceration; cornea and/ or sclera, perforating, not involving uveal tissue)-51-RT.

Coding tips: The National Correct Coding Initiative (NCCI) edits bundle 67036 (Vitrectomy, mechanical, pars plana approach) with 65265, so you would not include the code for the PPV. NCCI also bundles the magnetic and nonmagnetic foreign body removal codes; thus, the code you select should represent the final method of extraction.

Subsequent surgery – A few weeks later, during the post-op follow-up, the doctor noted the presence of hypotony, necessitating a second procedure. The patient underwent an examination under anesthesia, and slow anterior corneal and scleral wound leaks were found, requiring additional sutures. The surgeon also sutured the previous sclerotomy sites and reinflated the globe with a balanced salt solution.

Question: What ICD-10-CM codes do I report?

Answer: For these post-op complications you’d report the following diagnosis codes:

• T81.33xA (Disruption of traumatic injury wound repair, initial encounter)
• H44.431 (Hypotony of eye due to other ocular disorders, right eye)
• Z98.890 (Other specified postprocedural states)

Question: What CPT^® codes do I report for the subsequent surgery?

Answer: Submit 66020 (Injection, anterior chamber of eye (separate procedure); air or liquid). Because the ophthalmic surgeon performed the surgery within the global period of a related major procedure, you’d need to report the code with modifier 78 (Unplanned return to the operating/procedure room by the same physician … following initial procedure for a related procedure during the postoperative period) appended in order to be paid for this surgery.

“An exam under anesthesia was performed but is not separately billable. The NCCI edits bundle codes 92018 [Ophthalmological examination and evaluation, under general anesthesia … complete] and 92019 [… limited] with this and many ophthalmic surgery codes,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.