Ophthalmology and Optometry Coding Alert

Question: Is it appropriate to code an office visit with foreign-body removal? We usually do, and often get paid, using modifier -25, but sometimes an established patient comes in who knows "he got metal in his eye just hours ago," and the doctor removes it without incident. It doesn't seem proper to charge an office visit, because 65222 includes a slit-lamp exam. I realize a new patient, or an established patient who presents with just "eye pain," requires more examination and should have an office visit attached, but I'm not very clear on all of this.

Kansas Subscriber

Answer: Unless the physician finds it necessary to do a history, exam and decision-making with the performance of the foreign-body removal, you should not code for and bill the office visit.

If the physician thinks the patient requires a full workup to rule out other problems and considers this to be medically necessary, however, both services should be coded and billed. Documentation must substantiate the medical necessity. Your first step should be to ensure that the physician documented the history, exam and decision-making components of the complete exam in a separate, dated entry for the foreign-body removal.

Next: Choose an appropriate examination code (in this case it will most likely be an E/M code because the patient is presenting with a specific problem) depending on the documentation and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). By definition, modifier -25 is meant to be used with E/M services, but some carriers may allow or even require its use with the eye codes, as well.

Finally: For the diagnosis of the foreign-body removal, choose an ICD-9 code to best represent the ophthalmologist's findings in the examination. In other words, link the physician's diagnosis to the minor procedure code when reporting the claim. For example, an established patient presents with generalized pain in his eye, and the physician performs a level-two E/M service, 99212 (Office or other outpatient visit ...).

The physician makes a diagnosis of a foreign body in the patient's conjunctiva and decides to remove it; use 65205 (Removal of foreign body, external eye; conjunctival superficial). The correct coding for this scenario is 65205 linked to a diagnosis of 930.1 (Foreign body in conjunctival sac) and 99212-25 linked to a diagnosis of 379.91 (Pain in or around eye).

See "Test Yourself: Would You Append Modifier -25?" for more on modifiers and foreign-body removal.