Ophthalmology and Optometry Coding Alert

Question: How should I report the encounter when the ophthalmologist removes a pair of non-magnetic ocular foreign bodies (FBs) from the patient's cornea? Can I report two codes?

Minnesota Subscriber

Answer: You should report a single CPT code for both removals.

Explanation: When your ophthalmologist removes multiple foreign bodies from the same site of the same eye, you'll report a single procedure code regardless of the number of FBs present.

On the claim, report 65220 (Removal of foreign body, external eye; corneal, without slit lamp) if the doctor does the procedure without a slit lamp.

Check slit lamp use: If the doctor performs the removal with a slit lamp, instead use 65222 (... corneal, with slit lamp). Append modifier LT (Left side) to either procedure code to show the payer that the doctor worked on the patient's left eye, or RT for the right eye.

Diagnosis coding: Be sure to append ICD-9 code 871.6 (Penetration of eyeball with [nonmagnetic] foreign body) to your chosen CPT code to represent the FBs. So if the notes indicate slit lamp use, report 65222 with 871.6 appended to prove medical necessity. If the ophthalmologist removed foreign bodies from both eyes, report the code twice with modifiers LT and RT. Reimbursement is usually at 150 percent.