Ophthalmology and Optometry Coding Alert

Question: A new patient who had been taking down Christmas tree lights from his house the day before reports to the ophthalmologist with an irritated left eye. He says that one of the lights shattered while he was handling it, and he has been "wiping the eye out all day." The ophthalmologist examines the eye area, and notes "undetermined particles and small foreign bodies, but cannot confirm glass ... could just be pieces of leaves or grass." Using saline irrigation, the ophthalmologist cleans out the patient's eye and sends him home; no further tools are necessary. Is this an ocular foreign body removal (FBR), or is irrigation an E/M service?

Colorado Subscriber

Answer: This is a superficial conjunctival FBR, and it sounds as if an E/M also occurred. On the claim, report the following:

• 65205 (Removal of foreign body, external eye; conjunctival superficial) for the FBR

• an E/M code based on encounter notes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...)

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M to show that the E/M and FBR were separate services

• 930.1 (Foreign body in conjunctival sac) appended to 65205 and the E/M for the patient's injuries

• E914 (Foreign body accidentally entering eye and adnexa) appended to 65205 and the E/M to represent the cause of the patient's injury.

Explanation: For a corneal FBR, the ophthalmologist typically needs more tools than saline irrigation to remove the object[s]. When the ophthalmologist uses irrigation as the sole removal method, you can code the superficial FBR.