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Ophthalmology and Optometry Coding Alert

Look to Special Services, E/M Codes for Traumatic Eye Injury Care

Published on Thu Jul 07, 2005

Medicare may not like these codes - but emergency FB removals may be worth an extra $50

Treating ophthalmic emergencies in the office is difficult - so your office should get more reimbursement, right? Unfortunately, that's not always the way Medicare sees it, but our expert advice will help you get fair reimbursement for the ophthalmologist's extra work.

When a patient rushes in with a corneal laceration from glass stuck in his eye, you know that the ophthalmologist needs more time and skill than usual to deal with the traumatic eye injury. Yet Medicare has strict rules for coding ophthalmic emergencies in the office.

Some of the most common traumatic eye injuries ophthalmologists might treat in the office are foreign body (FB) removals (65205-65222) and laceration repairs (65270-65286). The code to report depends on the location of the FB and the resulting repair, if any.

For example, report 65205 (Removal of foreign body, external eye; conjunctival superficial) for a conjunctival FB and 65220 (... corneal, without slit lamp) or 65222 (... corneal, with slit lamp) for a corneal FB, says Shirley Laughman, coder and accounts receivable manager at the Campus Eye Center in Lancaster, Pa.

Include FB Removal in Corneal Repair

In some cases, the ophthalmologist must repair a laceration after removing a corneal FB. If you perform a laceration repair, use 65275 (Repair of laceration; cornea, nonperforating, with or without removal foreign body). Note that the code definition includes "with or without removal foreign body." This prevents you from reporting the FB removal in addition to 65275, even in the absence of a National Correct Coding Initiative bundle, says Carissa Baumhardt, CPC, coder and surgical coordinator at Ophthalmology Consultants in St. Louis.

When the FB is in the eyelid, use 67938 (Removal of embedded foreign body, eyelid). CPT says this procedure is blepharoplasty and must involve more than the skin. Code 67938 must involve the lid margin, tarsus or palpebral conjunctiva.

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

Reserve Special Services Codes for Private Payers

Treating traumatic eye injuries in the office often requires extra work from the ophthalmologist, which CPT recognizes by including 99058 (Office services provided on an emergency basis) to reflect the additional time and skill needed. CPT also contains a series of "after-hours" codes for services the ophthalmologist provides outside normal office hours:
 

  •  99050 - Services requested after posted office hours in addition to basic service
     
  •  99052 - Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service
     
  •  99054 - Services requested on Sundays and holidays in addition to basic service.

    Report these codes, if applicable, in addition to the basic service your ophthalmologist provides.

    Catch: Medicare has set no relative value units (RVUs) for these codes and will not pay for them separately - nor will many other carriers, says Tawnya Shanklin, coder and billing manager for Medical Eye Associates in Waukesha, Wis. These are all bundled codes, which means that they are always included with other services.

    Example: An established patient presents with generalized pain in his eye, and the ophthalmologist performs a level-two E/M service. He finds an iron filing in the patient's conjunctiva and decides to remove it. You should report 65205 (Removal of foreign body, external eye; conjunctival superficial), linked to a diagnosis of 930.1 (Foreign body in conjunctival sac). You also report 99058, which Medicare denies because it is included in 99212.

    Better way: Report 65205 linked to 930.1 and 99212-25 (Office or other outpatient visit ...; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to a diagnosis of 379.91 (Pain in or around eye).

    Why? For Medicare, you may be able to report the E/M service or the appropriate eye examination code (92002-92014) separately - if the E/M service is separately identifiable and sufficiently documented.

    Example: After doing lawn work, an established Medicare patient presents at the ophthalmologist's office complaining of a scratchy sensation from an FB in his left eye. The ophthalmologist examines the patient and discovers lawn debris embedded in the conjunctiva. There is no serious damage to the cornea.

    Report the applicable E/M code (99211-99215) with modifier 25 appended. Next, report 65210 (Removal of foreign body, external eye; conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating).

    Bright side: Some third-party insurers may reimburse for the emergency and after-hours codes - you'll never know unless you submit the claim. Further, omitting the code means you are not accurately reporting the patient's visit.
     
    To help justify reporting 99058, encourage your ophthalmologist to include the specifics of the emergency interruption. The documentation doesn't have to be extensive and could be as simple as a note that says, "Had to treat emergency patient out of turn."

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