Ophthalmology and Optometry Coding Alert

When ophthalmologists perform a foreign-body removal and an eye exam on the same day, they don't always get reimbursed but they should.

Ophthalmologists usually have to perform an eye exam prior to a foreign-body removal to identify the foreign body, but unless you have a handle on the documentation, modifier and diagnosis coding requirements, don't bet on getting reimbursed for both services.

Unfortunately, because an eye exam and the removal of a foreign body are typically performed one after the other, ophthalmologists can mistakenly document the foreign-body removal in the slit-lamp portion of the examination, giving the carrier the idea that the office visit service was an integral part of the minor procedure and, as such, was preoperative and included in the payment for the procedure. So your first step should be to ensure that the physician documented the history, exam and decision-making components of the complete exam in a separate, dated entry for the foreign-body removal, 65205-65222, 67938, 68530.

"It is always strongly recommended that if you are tying to justify that you are doing a separate procedure from the E/M service, you should have a separate procedure note, but it doesn't have to be on a separate sheet of paper," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. Rather, you should have a separate paragraph for the procedure note so your insurance carrier will know you really provided the patient with two separate and distinct services if you are reviewed, she adds.

Your next step is to choose an appropriate examination code (in this case it will most likely be an E/M code because the patient is presenting with a specific problem) depending on the documentation and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Nina Bagley, CPC, coding specialist for J. Michael Geiger, MD, in Fayetteville, N.C.

When using modifier -25, be sure you have all of the elements of the exam documented and that the E/M service's diagnosis code reflects medical necessity. You should also remember that you can append modifier -25 to either an E/M code or an eye code, Callaway says.

As for the diagnosis code for the procedure, in this case the foreign-body removal, choose an ICD-9 code to best represent the ophthalmologist's findings in the examination. In other words, link the physician's diagnosis to the minor procedure code when reporting the claim.

For example, an established patient presents with generalized pain in his eye, and the physician performs a level-two E/M service, 99212. The physician makes a diagnosis of a foreign body in the patient's conjunctiva and decides to remove it, code 65205* (Removal of foreign body, external eye; conjunctival superficial). The correct coding for this scenario is 65205 linked to a diagnosis of 930.1 (Foreign body in conjunctival sac) and 99212-25 linked to a diagnosis of 379.91 (Pain in or around eye).

"You won't necessarily have two separate diagnosis codes," Callaway says. "CPT guidelines state you don't need separate diagnosis codes when reporting a minor procedure and an E/M services separately, but there are some carriers that say they won't pay unless each service is linked to its own diagnosis code." Don't tweak your codes just to get through the system, though, she advises.