Ophthalmology and Optometry Coding Alert

Question: A patient reported with a foreign-body sensation after mowing the lawn and doing other yard work. Using a slit lamp, the ophthalmologist removed a superficial conjunctival FB and a corneal FB from a patient’s right eye; evidence of slit lamp use is in the notes. How should I code this?

Alabama Subscriber

Answer: Report CPT® code 65222 (Removal of foreign body, external eye; corneal, with slit lamp) for the removal of the corneal foreign body using the slit lamp. Report CPT® code 65205 (Removal of foreign body, external eye; conjunctival superficial) for the conjunctival FB.

Dx: Report ICD-9 code 930.0 (Corneal foreign body) connected to CPT® 65222 for the corneal foreign body. After Oct. 1, 2015, you would report the appropriate ICD-10 code, depending on which eye was affected:

• T15.00XA – Foreign body in cornea, unspecified eye, initial encounter

• T15.01XA – Foreign body in cornea, right eye, initial encounter

• T15.02XA – Foreign body in cornea, left eye, initial encounter.

For the conjunctival FB connected to CPT® 65205, report ICD-9 code 930.1 (Foreign body in conjunctival sac); after Oct. 1, 2015, report one of these ICD-10 codes: 

• T15.10XA – Foreign body in conjunctival sac, unspecified eye, initial encounter

• T15.11XA – Foreign body in conjunctival sac, right eye, initial encounter

• T15.12XA – Foreign body in conjunctival sac, left eye, initial encounter.

Room to grow: For both of the above ICD-10 code series, the sixth character “X” is a placeholder that allows for future expansion of the diagnosis code series. The final digit, “A,” assumes that this is the patient’s initial encounter for a foreign body. For a subsequent encounter, replace “A” with “D”; for sequela, use “S” as the seventh character.