Ophthalmology and Optometry Coding Alert

Are you cheating your practice out of deserved reimbursement?

Are you routinely selecting your foreign-body removal (FBR) code based on what instrument the ophthalmologist used? You may be reporting the wrong code — and collecting the wrong payments. Get the truth behind this and four other FBR myths that routinely trip up your ophthalmology coding colleagues.

Myth #1: The type of instrument the ophthalmologist uses determines what foreign-body removal code to report.

Reality: The codes in the FBR code series (65205-65222) do not indicate any particular instrument for removing the FB. However, CPT® code 65222 (Removal of foreign body, external eye; corneal, with slit lamp) does indicate the equipment used to enhance viewing of the affected area. You should choose a code according to the specific location and level of penetration of the FB in the eye.

For example, for the removal of a superficially penetrating FB in the conjunctiva, you would report 65205 (Removal of foreign body, external eye; conjunctival superficial). On superficial conjunctival FBRs, the ophthalmologist will typically use one of the following methods, or a combination of the three:

• irrigation
• a cotton swab
• the tip of a beveled needle.

This does not affect your code choice, however.

Not so fast: If the ophthalmologist performs an FBR in the cornea, you will need to consider whether he uses a slit lamp to visualize the FB. Report 65220.

(Removal of foreign body, external eye; corneal, without slit lamp) if he did not use the slit lamp; otherwise, report 65222 (... corneal, with slit lamp).

Myth #2: All FBRs within the same eye are bundled, which means you can only bill a FBR code once per eye.

Reality: This is true if the ophthalmologist removes multiple foreign bodies only from the same part of the eye. If he removes FBs from different parts of the same eye — the cornea and the conjunctiva, for example — you can separately report a code for each location.

Documentation is the key here, say experts, and the physician should draw a detailed diagram of the eye showing the specific location and depth of the foreign body(ies) removed.

In the Correct Coding Initiative, the codes concerning FBs in the conjunctiva, 65205 and 65210 (… conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating), are not bundled with corneal FB codes 65220 and 65222, which means you are free to report both codes — 65210 and 65222, for example — separately.

Good news: You can report a higher-paying code in 65210 if the ophthalmologist removes an embedded conjunctival FBR. In 2014, code 65210 has 1.99 total RVUs. Multiplying this by the 2014 conversion factor (35.8228) yields $71.29 in reimbursement. In contrast, code 65205 has only 1.64 total RVUs — leading to a reimbursement total of $58.75.

Bad news: No exact definition of “embedded conjunctival FBR” exists, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla..

Myth #3: You can’t code for both an FBR and an E/M service.

Reality: Like Myth #2, Myth #3 isn’t always a myth. If the physician found it necessary to obtain history, perform an exam (either prior to the foreign body removal or afterwards) with medical decision making, you should report the appropriate level of E/M service. This is true for new or established patients. It is up to the physician to document the circumstances that support medical necessity for the level of E/M service performed that was in addition to the procedure.

Whether you report an E/M code will depend on the patient’s complaint. If he just complains of eye pain, the ophthalmologist will probably need to examine the patient to find the source of the pain. Document the exact complaint the patient has if you want to defend using an office visit and an FBR procedure together.

Keep in mind: The payment for FBR contains an allowance for pre-procedure work necessary to evaluate the problem and perform the removal. Therefore, in order to bill separately for an E/M, the work performed cannot be for that purpose.

Conversely, the physician may note other issues during the procedure that warrant a closer look and require a full E/M workup following the procedure.

Smart idea: Be sure to document the history, exam, and medical decision making components of the E/M service in a separately identifiable medical record entry. You also need a procedural note separately documented for the FBR, and be sure that the ophthalmologist has signed and dated both sections. Choose an appropriate E/M code depending on the documentation and append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to this exam code.

Different ICD-9 codes for the exam and the FBR are not necessary, but some carriers may prefer that you have a distinct diagnosis for each service. The ICD-9 code for the E/M service should support medical necessity — the patient’s complaint of eye pain or a foreign-body sensation. And for the FBR, use an ICD-9 code that documents the findings during the procedure — the foreign body itself.

Myth #4: You can code a foreign body diagnosis even if your exam doesn’t turn up a foreign body.

Reality: You can code for the foreign-body sensation with an eye pain code, such as 379.91 (Unspecified disorder of eye and adnexa; pain in and around eye), but if the ophthalmologist’s exam revealed no foreign body, you should not report a foreign-body ICD-9 code (930.0-930.9, Foreign body on external eye).

Myth #5: You should code punctal plug removal as FB removal.

Reality: Punctal plugs may be foreign bodies, but reporting a punctal plug removal as an FBR will get you nowhere with Medicare. Unfortunately, there is no appropriate way to charge this service for Medicare patients. However, you may be able to charge for a low level E/M code if your ophthalmologist is not the one who performed the insertion.

There is no specific code in CPT® for the removal of a suture or implanted device; Medicare considers the removal to be included in the global package of insertion, even if it’s after the 10-day global period.