Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmologists uses a slit-lamp to check on healing after a foreign-body removal during follow-up visits. He wants to try to charge extra for using the slit-lamp, arguing that it takes additional time and expertise to do this. Granted, he used it the first time for the FB removal, but it seems a bit much to try to charge extra each time. How should we code and bill these types of visits?

North Dakota Subscriber

Answer: There is no code that describes only a slit-lamp exam without a removal of a foreign body. If the optometrist performs the exam as part of a follow-up encounter to evaluate the patient’s condition, only a low-level E/M code (99212) would be correct.

Link 99212 to the original complaint -- for example, 918.1 (Superficial injury of the eye and adnexa; cornea).

If the patient presented with pain or other symptoms that necessitated more care management, a third-level E/M code (99213) might be appropriate. But if the optometrist examines the eye -- even with the slit lamp -- and finds nothing, there’s no diagnosis, and therefore nothing to code or bill for.