Revenue Cycle Insider

Question: A patient presented to the emergency department (ED) with complaints of right eye pain. The patient was worried that a foreign body was in their eye because a cat touched the patient’s eye. After taking a history and performing a physical examination, an ophthalmologist arrived to evaluate the patient. The ophthalmologist used a slit lamp to remove the foreign body from the cornea.

What codes do I need to report?

Louisiana Subscriber

Answer: Starting with the visit to the ED, you’ll assign an appropriate ED evaluation and management (E/M) code from the 99281-99285 (Emergency department visit for the evaluation and management of a patient …) code range.

Next, you’ll assign a code that reflects the work of the ophthalmologist during the encounter. The CPT^® code set features several codes related to foreign body removal (FBR) from the eye, but only two specifically call out the use or nonuse of a slit lamp:

• 65220 (Removal of foreign body, external eye; corneal, without slit lamp)
• 65222 (… with slit lamp)

In your case, 65222 matches the provider’s work of removing the foreign body from the patient’s right cornea. You may also want to consider appending 65222 with modifier RT (Right side) to indicate laterality. Of course, review your individual payer guidelines for how they prefer you to report a unilateral procedure.

You’ll also need two ICD-10-CM codes to report this encounter, with one related to the diagnosis and one related to how the injury occurred. The ophthalmologist performed an FBR in the patient’s right cornea, so you’ll assign T15.01XA (Foreign body in cornea, right eye, initial encounter) to report the reason for the visit.

You’ll then assign W55.09XA (Other contact with cat, initial encounter) to indicate that the interaction with the cat was the cause of the injury. The W55.0- (Contact with cat) code set also includes W55.01- (Bitten by cat) and W55.03- (Scratched by cat) if the provider’s documentation offers further information on the encounter with the cat.

7^th character: You need the 7^th character “A” with both ICD-10-CM diagnosis codes to indicate that the patient is seeking active treatment for the injury. You also need to use a placeholder character, “X,” to fill the 6^th character spot and complete the code.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC