Ophthalmology and Optometry Coding Alert

Look closely at the documentation for these clues to determine the right code assignment.

A patient reports with a foreign body in her left eye. The ophthalmologist removes the FB and sends the patient home. This might look like a simple coding scenario, but there’s more to reporting ocular foreign body removal (FBR) than meets the eye. Your coding choice for these encounters will depend on depth of the wound, the location of the foreign body (FB) and the instrumentation the physician uses to perform the FBR.

Ask If Conjunctival FB Is ‘Embedded’ or Not

Ophthalmologists will typically treat two types of eye FBRs: conjunctival and corneal. On conjunctival removals, coders need to check if the FB was superficial or embedded, confirms Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, Okla.

When the ophthlamologist removes a superficial FB from the patient’s conjunctiva, report 65205 (Removal of foreign body, external eye; conjunctival superficial) for the service; for embedded conjunctival FBRs, choose 65210 (Removal of foreign body, external eyeconjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating).

What’s the difference?: A superficial FB is exposed to the surface and generally easily moved with a cotton swab. To remove a superficial FB, the ophthalmologist might use a swab, tweezers or an instrument called a spud. Embedded FBs extend into the conjunctiva. The ophthalmologist will likely use a needle or spud to dislodge the FBR, and the spud or tweezers to capture it. The deeper the FB is, the more likely the needle will be needed to dislodge it, Thomas says.

Example: A patient complains of odd sensations in his right eye. The patient says that he was within a few feet of an exploding light bulb earlier that day. The ophthalmologist finds a tiny shard of glass lying on the patient’s conjunctiva/conjunctival sac, which he grabs and removes using tweezers.

This is an example of a superficial FB, Thomas confirms. On the claim, report the following:

• 65205 for the FBR
• 930.1 (Foreign body in conjunctival sac) linked to 65205 to represent the FB
• E914 (Foreign body accidentally entering eye and adnexa) linked to 65205 to represent the cause of the injury.

In this case, a low level E/M would also likely apply. Don’t forget to append the -25 modifier to your 9928x E/M code.

Instrumentation Drives Corneal FBR Coding

When the ophthalmologist removes a patient’s corneal FBR, you’ll need to rely on a different set of codes.

If the ophthalmologist removes the FBR without a slit lamp, report 65220 (Removal of foreign body, external eye corneal, without slit lamp). Report corneal FBR removals using a slit lamp with 65222 (Removal of foreign body, external eye; corneal, with slit lamp).

The ophthalmologist must be very careful not to damage the eye if the patient has an FB in his cornea. A slit lamp provides a beam of light and magnifies the FB. So if the ophthalmologist is having trouble visualizing the FB for removal, he may employ a slit lamp. On your corneal FBR claims, be sure to check for slit lamp use before coding, Thomas explains.

Example: A patient reports with pain in his left eye. The ophthalmologist examines the area, finding several paint chips in the cornea. The ophthalmologist is able to see two paint chips, but is not convinced that the patient only has two FBs. She then uses a slit lamp to visualize the cornea, at which point she finds another small paint chip. The ophthalmologist removes the three paint chips.

Since the ophthalmologist decided to use the slit lamp to check for further particulate, you should report this service with 65222.

Conjunctival/Corneal Combo Calls for Two Codes

In the event that a patient requires removal of both a conjunctival and corneal FB from the same eye, choose codes for each service. But don’t be surprised if the carrier reduces payment for one of the removals. You would code the corneal FBR and the conjunctival FBR as normal, but you will probably get a multiple surgery reduction of fees depending on the carrier. You should bill each code for the full amount, and let the carrier reduce them if it wants. Use of modifier 51 (Multiple procedures) might speed the claims process with certain payers, says Thomas.

Best bet: Some payers might want to see modifier 51 on claims in which the ophthalmologist removes FBs from different sections of the same eye; others will just make the multiple surgery reduction when they receive the claim. If you are unsure of the payer’s policies on this issue, check your contract before coding.

Example: A welder reports with swelling in his left eye. The ophthalmologist finds metal flakes over the patient’s conjunctiva/conjunctival sac and cornea, though none of it is embedded. The ophthalmologist removes two conjunctival flakes with tweezers, then uses a slit lamp and needle to remove a flake from the cornea.

On the claim, you should report the following:

• 65222 for the corneal FBR with slit lamp.
• 930.0 (Corneal foreign body) linked to 65222 to represent the corneal FB
• 65205 for removal of the conjunctival FBR
• 930.1 (Foreign body in conjunctival sac) to linked 65205 to represent the patient’s conjunctival FB.

Also, link modifier 51 to 65205 to represent the separate nature of the FBRs — if your carrier requires it.