Ophthalmology and Optometry Coding Alert

Tip: Coding depends on location of the ocular foreign body.

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.

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.

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.

If the ophthalmologist removes FBs from different anatomical parts of the same eye, however, then you can report a pair of codes.

Example: The ophthalmologist removes a superficial conjunctival FB and a corneal FB from a patient’s right eye; evidence of slit lamp use is in the notes. On the claim, you would report the following:

• 65222 for the slit lamp removal with 930.0 (Corneal foreign body) appended to represent the FB
• 65205 for the conjunctival removal with 930.1 (Foreign body in conjunctival sac) appended to represent the FB.

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.

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.

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 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) 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 provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service

99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, 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. These are all bundled codes, which means that they are always included with the basic service.

Example: An established patient presents with generalized pain in his eye, and the ophthalmologist performs a level-two E/M service. During the examination component, 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).

Pair 99058 With E/M Code

You should also report 99058, in addition to E/M service 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient …; Significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service). 

Although Medicare will deny 99058 as it considers this a bundled service with the E/M service and not separately payable, some private insurers might pay for 99058. Reporting 99058 to Medicare or any other payer is only done when also reporting an E/M code.

For Medicare, you should only 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. If the physician saw the patient and immediately examined the patient’s eye to find the foreign body as a prelude to an expected foreign body removal, this work is included in the procedure for removal of the foreign body and an E/M should not be separately coded and billed. Insurers consider the E/M pre-operative work necessary to perform the procedure. 

However, if following the procedure the physician notes the patient has severe dry eye damage and determines a need to do a complete history, exam, and treatment, then the E/M is separately identifiable and you should document and code to the corresponding level of service. In this case, a separate diagnosis for dry eye syndrome (375.15, Tear film insufficiency, unspecified) supports the E/M service.

Example: After doing lawn work, an established Medicare patient presents at the ophthalmologist’s office complaining of a scratchy sensation in his left eye. He tells the physician that the problem started following some lawn work and he thinks he may have gotten something in his eye. The ophthalmologist examines the patient and discovers lawn debris embedded in the conjunctiva of the left eye. There is no serious damage to the cornea but the physician also notes that the patient has severe blepharitis in both eyes. Following the removal of the foreign body, the physician performs a complete work-up and also treats the blepharitis. 

Report the applicable E/M code (99211-99215) with modifier 25 appended linked to the diagnosis for blepharitis (373.0x, Blepharitis …). Next, report 65210 (Removal of foreign body, external eye; conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating) linked to the appropriate foreign body diagnosis. If the physician is surgically treating the blepharitis, you can also code separately for blepharoplasty (15820-15823, Blepharoplasty …).

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, “Patient presented to the office for an unscheduled visit due to the need for emergency care.”