Ophthalmology and Optometry Coding Alert

These 3 common ophthalmology scenarios clear up when you can -- and can't -- separately report E/Ms

When a minor procedure requires additional up-front work, you may be entitled to additional reimbursement -- if you have the necessary documentation to append modifier -25 to a separate E/M service.

Many private carriers -- and most Medicare carriers -- will separately reimburse for minor procedures and office visits with correct coding and sufficient documentation.

The next time your ophthalmologist inserts a punctal plug -- or performs another minor procedure, such as a foreign-body removal -- reference these scenarios to determine whether the carrier should reimburse you for the office visit in addition to the minor procedure, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

Punctal Plugs

Code the procedure with an eye/lid modifier and the office visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). A patient reports dry, itchy eyes and generalized pain. The ophthalmologist performs a complete eye exam -- separate from the procedure -- to rule out other causes, and he diagnoses dry eyes. He places collagen punctal plugs in the two lower puncta to see if this resolves the problem.

Report 68761 (Closure of the lacrimal punctum; by plug, each) on two lines and append -E2 (Lower left, eyelid) and -E4 (Lower right, eyelid), plus modifier -51 (Multiple procedures) to denote the lids, says Donna Marks, CPC, CCS-P, coder for the Lahey Clinic Department of Ophthalmology in Burlington, Mass. For example, you would report 68761-E2, 68761-51-E4. Link 375.15 (Other disorders of lacrimal gland; tear film insufficiency, unspecified) to the punctal plug closure codes. Also report the appropriate-level E/M service with modifier -25 and link it to 379.91 (Pain in or around eye).

Code the procedure alone. The same patient returns for a follow-up visit in three weeks and reports great improvement following the punctal plug placement. The ophthalmologist replaces the temporary plugs with permanent silicone ones. Report the surgical procedure again, as above, and link it to 375.15 for the dry-eye syndrome. You should not separately report an E/M service when the service was an "integral and preoperative" part of the plug placement.

Foreign-Body Removal

One of the trickiest examples of using modifier -25 is for an office visit with a foreign-body removal. Many ophthalmologists perform an exam, identify the foreign body and attempt to remove it during the same-day patient encounter. The issue becomes one of documentation, Duran says.

The ophthalmologist must document the history, exam and medical decision-making first and then do a dated entry for the procedure.

But when the ophthalmologist makes the mistake of describing the foreign-body removal in the slit-lamp portion of the exam, the exam may appear to carriers as though it is included in the preoperative portion of the minor surgery's global surgical package. (See "Cover All Your Documentation Bases for a Payment Home Run" for tips on how to navigate this challenge.)

Code the procedure performed and the separately documented office visit appended with modifier -25. A patient complains of pain and tearing, and the ophthalmologist performs a complete exam to determine the cause. She subsequently finds a corneal foreign body. The doctor removes the foreign body -- 65222 (Removal of foreign body, external eye; corneal, with slit lamp) -- which you would link to 930.0 (Foreign body on external eye; corneal foreign body). You should then append modifier -25 to an E/M code based on the extent of the service performed and separately documented and link it to 379.91.

Code the procedure only. Occasionally a patient, such as a construction worker, will present and know there is a foreign body in his eye. He generally knows how he felt when it started and how the foreign body got in his eye. And he has often tried to remove it himself by trying to wash it out or get the foreign body to stick to a magnet if he knows it is metallic. Under these circumstances, the physician may proceed directly to performing the removal without a full workup, and you should report only the procedure code (65222).

Epilation for Trichiasis

Code the procedure and office visit with modifier -25: A patient complains of a red eye and a "scratchy, foreign-body sensation." The doctor deems it medically appropriate to do a complete workup of the patient's history, performs an exam and diagnoses a lash growing in toward the eye causing irritation. He then removes the lash. Report 67820 (Correction of trichiasis; epilation, by forceps only) and link it with 374.05 (Other disorders of eyelids; entropion and trichiasis of eyelid; trichiasis without entropion). Bill the E/M service with modifier -25 and link it to 379.91.

Code the procedure alone: An established patient with chronic trichiasis problems comes in and reports that he has another ingrown eyelash. (Patients who have had this recurring condition recognize it.) The ophthalmologist looks with the slit lamp to locate only the aberrant lash, agrees, and removes it. You should report 67820 with 374.05, and no office visit.