Ophthalmology and Optometry Coding Alert

Coding for an ocular foreign-body removal (FBR) seems simple: The ophthalmologist finds the FB, removes it and sends the patient home.

Not so fast: Knowing what happens during that encounter is vital to correct coding. You have to know the FB's specific location and the ophthalmologist's actions during the session before arriving at the proper code.

An ophthalmologist can remove two distinct types of FBs from a patient's eye: a conjunctival FB or a corneal FB. For conjunctival FBRs, coders need to know if the FB was superficial or embedded because the code choice will hinge on this information.

If the ophthalmologist removes a superficial conjunctival FB, code the service with 65205 (Removal of foreign body, external eye; conjunctival superficial). If the ophthalmologist performs removal of an embedded FB from the conjunctiva, choose 65210 (... conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating) instead.

How can I tell? Your surgeon may also refer to a superficial FB in encounter notes as a "loose" FB. "A superficial FB usually sits on the surface (of the conjunctiva), whereas an embedded FB is just that: embedded," says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla.

"For a superficial FBR in the conjunctiva, a doctor uses something simple, like a moistened, sterile Q-tip; this works very well with larger FBs, such as dirt particles or ash," Martien says.

With embedded FBRs, the ophthalmologist may use a cotton swab for the procedure, but the doctor may also have to scrape out the FB area with a needle. Embedded conjunctival FBRs sit in the conjunctiva but have not penetrated the anterior chamber.

You code it: A house painter with a swollen left eye reports to the ophthalmologist. The doctor examines the patient and finds a paint chip sitting atop the patient's conjunctival sac. Using a moistened swab, the doctor removes the FB.

On the claim, you should report the following:

• 65205 for the superficial FBR.

• 930.1 (Foreign body in conjunctival sac) to support medical necessity for the procedure.

Like conjunctival FBRs, corneal FBRs have their own code set. Although the difference between 65205 and 65210 is the FB's location, corneal FBR codes are separated by slit-lamp use. The doctor might need to use a slit lamp for visualization of hard-to-see corneal FBs.

In a nutshell: When the ophthalmologist removes an FB from the cornea, you'll need to check the op note to determine the approach and method of removal before you choose a code. If the doctor removes an FB from a patient without using a slit lamp, report 65220 (... corneal, without slit lamp). When the doctor needs to use a slit lamp for the FBR, opt for 65222 (... corneal, with slit lamp).

Often, the corneal FB isn't readily visible to the examiner. By using the slit lamp, the ophthalmologist may be able to see a microscopic FB he might otherwise have overlooked. The slit lamp is not necessary for conjunctival FBs, which are easier to locate against the white backdrop of the conjunctiva.

Example: A patient with a red and itchy right eye reports to the ophthalmologist. The doctor examines the conjunctiva and finds no evidence of FB. He then examines the cornea and finds signs of trauma, but no FB. The doctor uses a slit lamp to visualize the cornea, finds an FB and removes it with a combination of sterile swabbing and scraping with a needle. In this scenario, you should report 65222. Don't forget to link 930.0 (Corneal foreign body) to 65222 to represent the FBR.

Remember that when your doctor removes multiple FBs from the same part of the same eye, you should only code once for it. So if the notes indicate that the ophthalmologist removed three superficial FBs from the patient's right conjunctiva, you should report 65205 once. If, however, the ophthalmologist removes FBs from different parts of the same eye, you might be able to report the codes separately.

Example: The ophthalmologist removes conjunctival and corneal FBs in the patient's right eye. The conjunctival FB is superficial, and the ophthalmologist does not use a slit lamp for the corneal FBR. In this case, report the following:

• 65220 for the corneal FBR

• 930.0 linked to 65220 to represent the corneal FB

• 65205 for the conjunctival FBR

• 930.1 linked to 65205 to represent the conjunctival FB.

Note: Some payers may require you to use modifier 59 (Distinct procedural service) with 65205 to show that it was a separate service from the corneal FBR. If you have questions, check with your insurer before filing the claim.

"Clear documentation is key when reporting the multiple FBRs, as these two codes are bundled and can only be appropriately unbundled for separate site of service," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "A drawing of the location of the foreign bodies may also be beneficial."

Watch out: You might be tempted to use 65235 (Removal of foreign body, intraocular; from anterior chamber of eye or lens), 65260 (... from posterior segment, magnetic extraction, anterior or posterior route) or 65265 (... from posterior segment, nonmagnetic extraction), but remember that these are "facility-only" codes, usually performed in a hospital or similar facility, not in the ophthalmologist's office.