Ophthalmology and Optometry Coding Alert

Sometimes a relatively simple procedure evolves into totally unpredictable multiple visits in one day. Not only is the day harrowing for the patient, but it can be a coding nightmare.

Take the case of a patient who has a chalazion excision (67800) in the minor room. Two hours later, this patient returns to the office with profuse bleeding. The wound requires additional cauterization, and approximately one hour of care. How should you code this day?

Under most circumstances, you will only be able to bill for the initial 67800, even if you did spend an hour taking care of the wound later in the day, explains Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care, a nine-ophthalmologist group based in Louisville. It doesnt matter if the complications arise on the same day, or on any subsequent day, until 10 days have gone by. If the patient is seen again, within 10 days, with a problem related to the surgery, its covered by the chalazion excision code global surgical package, says Oyler. Its all post-op care that does not require returning the patient to an operating room, and is therefore part of the global fee.

Note: Code 67800 has a postoperative period of 10 days. Other surgical codes may have 0, 10, or 90 days included in the package under the RBRVS system.

But if the wound didnt reopen spontaneouslyif, instead, the patient fell, for exampleyou could get paid for the extra work you did that day, says Oyler. If so, you would use a different diagnosis code, and then you could use an E/M services code for the office visit. You would use either an E/M code that reflects the services rendered or the physician face-to-face time spent with the patient to stop the bleeding for the second visit, says Oyler. It would probably be at least a 99213 because of the medical complexity.

You should also put a modifier -24 on the E/M code, Oyler says. This indicates an unrelated evaluation and management service by the same physician during a postoperative period. The reason for this service must be unrelated to the original procedure, according to CPT.

Finally, the primary diagnosis code for the E/M service should be the injury (if the patient fell). The ICD-9 code might be something like 921.1 for contusion of eyelids and periocular area.