Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist saw a patient yesterday who had a conjunctival foreign body. I billed 65205 and 92012. Then I saw an article that said I couldn't bill for both an office visit and the procedure on the same day. Is that true?

Minnesota Subscriber

Answer: Unless the ophthalmologist does a complete workup (history, exam and decision-making) prior to or following the performance of the FBR, you should not code and bill an E/M service or eye code (92012, Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) along with the foreign-body removal (65205, Removal of foreign body, external eye; conjunctival superficial).

But if the ophthalmologist determines it is medically necessary for a full workup due to other problems or as a necessary adjunct to perform the FBR procedure, you should code and bill both services. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code (and, for some payers, to the eye codes) when reporting both services.

Whether or not to bill an E/M code depends on what the patient relates to the ophthalmologist. If the patient says that his eye hurts without any indication of cause, an office visit is needed to diagnose and treat the patient. Document the exact patient complaint and the need for workup prior to or following the FBR procedure to support billing both services.

The practice may not get reimbursed for both services, however, if you don't follow the documentation, modifier and diagnosis coding requirements for reporting an E/M service and an FBR on the same day. If you document the FBR procedure in the slit-lamp portion of the examination, the carrier may assume that the office visit service was an integral part of the minor procedure and therefore included in the payment for the procedure.

Solution: Be sure to document the history, exam and decision-making components of the E/M service in a "separately identifiable", dated entry from the FBR procedure documentation. Choose an appropriate examination code depending on the documentation, and append modifier 25. You may have the same diagnosis for both services or separate diagnoses depending on the circumstances for the encounter. In the case above, the E/M service would be linked to a diagnosis of "eye pain" (379.91, Pain in or around eye) and the FBR procedure linked to a diagnosis of "foreign body" (930.x, Foreign body on external eye).

Smart idea: Put the notes for the FBR on a special FBR form. Keep the notes for the office visit on a separate form.

Bottom line: If the patient comes in and points to the foreign body on his conjunctiva, the ophthalmologist may not need an E/M workup to determine treatment and will begin the FBR procedure immediately. However, any other symptoms, problems, or concerns to be addressed at the same visit may support an E/M service. If the patient comes in and says he has pain in an eye and doesn't know why, then the ophthalmologist will start with a history and examination to determine what the cause of the eye pain is. Once the ophthalmologist determines the patient has a foreign body, he will need an additional and separate procedure to treat the patient.