Ophthalmology and Optometry Coding Alert

Eye injuries sustained on the job may require the ophthalmologist to bill a workers' compensation carrier. But, sometimes patients present with a work-related injury and a nonwork-related injury. Coders must know how to split-bill and document these cases to ensure adequate and ethical reimbursement.

State boards oversee workers' compensation carriers, which use CPT codes for claims, explains Cam Teems, senior consultant for Gates, Moore, an Atlanta-based medical consulting firm. "Most health plans won't pay for a work-related injury," Teems says. "Instead, that payment is covered by workers' compensation."

In most states, if an employee is injured at work, he or she is directed to a panel of physicians who have contracted to take workers' compensation cases. A physician who serves on such a panel generally agrees to the rates and code bundles of the workers' compensation carrier.

If a physician isn't enrolled with workers' compensation and a patient presents with a work-related injury, the physician may have difficulty getting paid, Teems says. "The best thing you can do if you're not contracted is to refer the patient, if stable, to the emergency room or to a physician who is contracted."

Keep separate notes for each kind of code injury versus non-injury if you split-bill, recommends Melissa K. Duchak, CPC, an ophthalmology coding consultant based in Piscataway, N.J. The following examples illustrate how to split-bill workers' compensation cases:

A patient comes in with a minor corneal abrasion (918.1, Superficial injury of eye and adnexa; cornea) caused by flying dust and debris on the job. The physician examines the patient, billing a lower-level E/M service (99201-99202, 99212-99213) for the anterior segment exam. The patient states that before the current problem with the dust and debris, he had vision problems and requests a complete eye examination to determine the cause. Bill the vision portion of the visit with an eye code (most likely 92002) unless there is justification to repeat all parts of the eye examination, Duchak says. If the patient has a medical condition such as cataracts, link the 920xx code to the diagnosis code for cataract (366.xx). File the injury claim with workers' compensation, and the eye code claim with the patient's private insurance.

A patient presents with a complaint of a foreign-body sensation after walking past a renovation work area, but no foreign body is found. In fact, the foreign-body sensation has dissipated since the employee left the workplace. The patient also states that she hasn't been seeing well while driving at night and, since she hasn't been to an ophthalmologist in years, wants it checked. In this case, bill one code (99201-99215; consultation, 99241-99245) to the workers' compensation carrier, and one code (99202-99214) to the patient's insurance. "If the other service is not injury-related, you can split-bill," Teems says. "But if you were ever audited, your documentation would have to be clear on what was related to the injury and what wasn't." Also, the codes submitted must reflect the work done for each problem and must not appear to be double-billing. This is why separate documentation of each service is important.

Instead of split-billing, you may ask the patient to return for the non-injury visit at another time. Bill the patient's insurance for the service rendered at the next appointment, billing workers' compensation for the services related to the injury. This is the clearest, safest way to handle billing but may not be the most convenient for the patient.

Regardless of whether you want to split-bill, a refraction (92015, Determination of refractive state) usually can't be done if a patient has an injury, however minor, that is causing tearing, says Philip L. Levy, MD, a Sacramento ophthalmologist and past president of the California Academy of Ophthalmology. "You wouldn't get an accurate result with a refraction if the patient had an eye irritation," Levy says. "So I would tell the patient I'd do the full dilated exam and a glaucoma test unless contraindicated by the injury, but not a refraction because the prescription wouldn't be correct. The patient should return another day for the refraction." If the patient has no other medical condition and the trouble with vision is refractive error, a single bill should be submitted to workers' compensation unless the patient has a vision plan that will pay for a routine eye examination with refraction.

Sometimes the work-related injury requires surgery the same day the physician sees the patient. To receive reimbursement from Medicare for the visit (99201-99215, 99241-99255) and the surgery, you must append modifier -57 (Decision for surgery) to the E/M. Workers' compensation, however, may roll the consultation into the surgery.

For example, an employee is operating a forklift when a box of merchandise hits him in the eye, lacerating it so seriously that it cannot be saved. The ophthalmologist examines the patient and probably reports a high-level E/M code (99204, 99205) or if the patient is admitted (99254, 99255), with a diagnosis of 871.2 (Rupture of eye with partial loss of intraocular tissue). The ophthalmologist performs an enucleation that day, coding 65101-65105. For Medicare, appending modifier -57 to 99215 (or a lower-level code) should guarantee payment even though the visit was within the global of the surgery. For workers' compensation, modifier -57 may be incorrect.

Sometimes a work-related injury involves services that are rendered after the event but are related to the injury. For example, an employee in a wood mill gets a small splinter of wood embedded in his cornea. It has not perforated the cornea but requires removal using a slit lamp (65222*, Removal of foreign body, external eye; corneal, with slit lamp), antibiotic drops, and a patch (the drops and patch are included in the global surgery package for the minor procedure). The ophthalmologist codes an office visit (99201-99215) with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and 65222 for the removal. Five days later a fungus infection develops. Corneal surgery, such as lamellar keratoplasty (65710, Keratoplasty [corneal transplant]; lamellar) or penetrating keratoplasty (65730, penetrating [except in aphakia]), is necessary. Because the original injury was work-related, workers' compensation claims are appropriate.

Employers frequently pay for less expensive work-related injuries directly instead of having the physician file for workers' compensation. "That's very reasonable," Teems says. "It's up to the employer." However, if the original work injury was not filed and a more serious surgery is later required, the employer will have to pay for that care as well.

Even if the employer is paying the employee and not filing a claim for workers' compensation, Levy cautions, you should still report the injury to the department of statistics. "If the employer doesn't want to file a claim with his or her carrier, but just wants to pay you, that's fine," he says. "But you must file a report to the department of statistics."