Ophthalmology and Optometry Coding Alert

Don’t skimp on coding when you see a patient with an urgent diagnosis.

While the primary focus of eye care practices revolves around scheduled appointments for medical services, ophthalmologists and optometrists also treat patients with urgent eye conditions. These may not be the codes you’re accustomed to reporting, but billing these cases requires the same level of precision and attention to detail.

Check these eye trauma scenarios and determine if you know how to code the scenario before reading our answers and expert advice.

Identify What Exam Codes Include

Question: An 8-year-old new patient presents to the retina specialist with his mother complaining of decreased vision after getting hit in the left eye with a soccer ball. Visual acuity is 20/200 in his right eye and 20/20 in his left. A comprehensive dilated exam of the left eye reveals there is no blood in the anterior chamber or vitreous, but there is commotio retina involving the macula. The physician instructs the mother to monitor the patient closely and return in one week, or sooner if the patient complains of pain or change in vision, for a re-evaluation and macular scan.

One week later, the patient returns for a follow-up visit. The physician notes the commotio retina has resolved, but his visual acuity is only 20/100. Optical coherence tomography (OCT) of the macula reveals a partial thickness macular hole.

How would you code each visit? Specifically, what CPT^® and ICD-10 codes are reported for the first visit, and is it appropriate to bill for the exam and OCT for the second?  

Answer: For the initial encounter, which included a comprehensive dilated exam, you can either submit evaluation and management (E/M) code 99203 (Office or other outpatient visit for the evaluation and management of a new patient … low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) or eye visit code 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits).

Because the patient’s left eye was affected, you’ll report S05.92XA (Unspecified injury of left eye and orbit, initial encounter) for this situation. If you can directly correlate the ocular injury to being hit with the soccer ball, you can also report an external cause of injury code to describe the accident, such as W21.02XA (Struck by soccer ball, initial encounter).

You’ll submit two CPT^® codes for the subsequent encounter, one for the exam and 92134 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina) for the OCT. The National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits do not bundle OCT with the exam codes, so it is appropriate to bill for both. The correct ICD-10 code for the second visit is H35.342 (Macular cyst, hole, or pseudohole, left eye).

Sequence These Orbital Fracture Codes

Question: A 42-year-old patient presents with multiple specified fractures on the same orbit. Should you use one diagnosis code, or code each specific fracture on the same orbit?

Answer: The answer will depend on how the physician documents the fractures in the record, says Gina Vanderwall, OCS, CMBS, CPC, CPPM, CPC-I, MFG coding educator with the University of Rochester Medical Center in Rochester, New York. ICD-10-CM Guidelines indicate, “Multiple fractures are sequenced in accordance with the severity of the fracture.”

If the physician has just evaluated the patient for the fractures to make sure no surgery is indicated, the most severe fracture would be sequenced first, with the remaining fractures coded in hierarchical order and the diagnosis codes linked to the applicable E/M code, Vanderwall explains.

For example, if a patient presented to the emergency department with a severe fracture of the medial orbital wall of the left eye and a mild fracture of the lateral orbital wall of the left eye, then you would report the following diagnosis codes:

• S02.832A (Fracture of medial orbital wall, left side, initial encounter for closed fracture)
• S02.842A (Fracture of lateral orbital wall, left side, initial encounter for closed fracture)

The medial orbital wall fracture is listed first since the severity of that injury is greater than that of the lateral orbital wall. If you know the cause of the injury, you can also report another code to describe the source of the injury.

On the other hand, if the physician surgically treats one of the specific fractures, then you’ll link the fracture care code to the diagnosis for the fracture treated during the surgery.

Examine All Options for This Early Morning Eval

Question: A 27-year-old accidentally pokes their eye with a pen, causing their right eye to completely fill with blood. The patient was able to reach the ophthalmologist on call, who agreed to see them in the office at 8:15 am, before the clinic’s regularly scheduled office hours that day. The patient does not report any pain associated with the injury. The physician diagnoses the patient with a subconjunctival hemorrhage. Which code(s) apply?

Answer: For a conjunctival or subconjunctival hemorrhage, the same ICD-10 series applies: H11.3- (Conjunctival hemorrhage). These must be coded out to the 5th character, with the final digit denoting the eye(s) affected.

In this case, the hemorrhage occurred in the patient’s right eye, so you’ll report H11.31 (Conjunctival hemorrhage, right eye) for the diagnosis.

Tip: Consider submitting 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service) in addition to the appropriate level of E/M or eye visit code. “Code 99050 is payable by some commercial plans, but not all, and it is not reimbursed by Medicare,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

“If the code is not paid separately by the plan, the charge will need to be adjusted off — it would not be appropriate to pass the charge on to the patient,” she adds.