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Ophthalmology and Optometry Coding Alert

Reader Questions:

Report E/M for Follow-Up Exams After FB Removal

Published on Sun May 23, 2010

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 SubscriberAnswer: There is no code that describes only a slit-lamp exam without a removal of a foreign body. If the ophthalmologist performs the exam as part of a follow-up encounter to evaluate the patient'scondition, only a low-level E/M code (99212) might 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 and [...]
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