Ophthalmology and Optometry Coding Alert

Question: How should we code a corneal foreign-body removal? Can we charge for an office visit as well?

Texas Subscriber

Answer: Yes, you can charge an office visit with corneal foreign-body removal. The codes for foreign body removal are 65220* (Removal of foreign body, external eye; corneal, without slit lamp) and 65222 ( corneal, with slit lamp). Almost all foreign-body removals are performed with a slit lamp. Occasionally, however, the ophthalmologist may report to the emergency department (ED), which does not have a slit lamp. In this case, the physician can still perform the removal using loops. Anesthesia is topical and included in the procedure.

As for billing an E/M service in addition to the foreign-body removal, a typical example involves a patient who comes to the office complaining of pain in her eye. The ophthalmologist performs an appropriate examination and engages in medical decision-making. The physician should record the history, the exam, the impression and plan separately from the documentation for the removal of the foreign body. You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service to show that it was significant and separate from the foreign-body removal.

Nonetheless, ophthalmologists frequently include information about the foreign-body removal under the slit-lamp portion of the documentation. Foreign-body removal is a minor procedure, and minor procedures include preoperative work. If what is documented looks integral to the procedure and is not a separate service, the payer will not reimburse for it.

You should not code for an E/M service in addition to the foreign-body removal if, for example, a patient reports to the ED, has seen an ED physician, and you are called in to remove a foreign body already identified in the cornea. You examine it, remove it and patch the eye. There is no separately documented examination and no separately billable service. Of course, you may code the minor procedure of removing the corneal foreign body.

In another less frequent example, the physician occasionally will remove the foreign body and perform the exam the next day. Typically, the patient meets the physician after hours in the office for the foreign-body removal. For the sake of convenience, the physician asks the patient to come back the next day for a full examination. The services are billed separately with no modifiers.