Ophthalmology and Optometry Coding Alert

Question: A patient came in for a foreign-body removal. We billed the workers' comp carrier for the removal (65222) along with the office visit (92012). We appended modifier -25 on the office visit. They paid us for the removal, but they are refusing to pay the office visit, saying it is included. Should I fight this denial or just let it go?

Maryland Subscriber

Answer: Most carriers follow Medicare's policy that all CPT codes - including 65222 (Removal of foreign body, external eye; corneal, with slit lamp) - have an inherent E/M component. To properly code using modifier -25, the ophthalmologist must perform an E/M service that is separate and identifiable from any minor procedure. Your documentation must include the E/M service as well as the procedure. If the ophthalmologist's chart notes support a separate office visit, you should appeal the decision with your documentation.

Note: For practices that see a fair percentage of workers' comp patients, you should know the fee schedule for your state. Workers' comp programs are usually run by your state's Department of Labor, which may be able to help you locate a Web site or phone number. To search for state Web sites, go to www.workerscompensation.com/ or www.comp.state.nc.us/ncic/pages/all50.htm.