Ophthalmology and Optometry Coding Alert

Question: A patient with eye pain presented to our office. This is a Medicare patient our ophthalmologist has seen before for other problems. During this visit the ophthalmologist performed a level-two E/M service and found an iron filing in the patient's conjunctiva. The doctor then removed the filing in the office. Can I report the foreign-body removal and 99212? Alabama Subscriber Answer: No. Based on the information you provided, payers will consider the service your ophthalmologist performed to be part of the foreign-body (FB) removal. Why? You should code a separate E/M service only if the physician has to perform a separate E/M to assess another problem, or a separate E/M was medically necessary prior to performing the FB removal. Determining the foreign body's location in the patient's eye is an integral part of the procedure, and payers include that service in the removal procedure. You're correct that you should report the FB removal with an FB procedure code. In this case, report 65205 (Removal of foreign body, external eye; conjunctival super-ficial) linked to 930.1 (Foreign body in conjunctival sac). If your ophthalmologist performs a separate E/M service to evaluate another problem or condition, there must be separately identifiable documentation in the medical report to support both the service level rendered and medical necessity for the additional work separate from the FB removal. Then, you would report the appropriate E/M service level (99211-99215) appended with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).