Ophthalmology and Optometry Coding Alert

Question: A patient with a foreign body in her left eye presents to our office for treatment. The ophthalmologist performed foreign-body removal (FBR) from the cornea with a slit lamp after conducting a level-three evaluation and management service to check for further injury. How should I report this encounter?

Connecticut Subscriber

Answer: You'll be able to report a pair of CPT codes in this instance -- one for the E/M and one for the FBR. On the claim:

• Report 65222 (Removal of foreign body, external eye; corneal, with slit lamp) for the FBR.

• Report 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...).

• Attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99203 to show that the E/M was indeed a significant and separate service from the FBR.

• Link 930.0 (Foreign body on external eye; corneal foreign body) to 65222 and 99203 to prove medical necessity for the encounter.

Remember: If your physician performs corneal FBR without using a slit lamp, it affects your code choice. If the ophthalmologist does not use a slit lamp, you should report 65220 (... corneal, without slit lamp) instead of 65222.

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, in Clearwater, Fla.