Ophthalmology and Optometry Coding Alert

You Be the Coder:

Check for Slit Lamp Use Before Coding Corneal FB Removal

Published on Tue Aug 23, 2022

Question: Our ophthalmologist saw a patient complaining of pain and discomfort in his right eye. The patient said that he was using an electric hedge trimmer on a tall hedge in his yard earlier that day. The physician examined the area and found several tiny pieces of wood in the cornea, which she removed. Can we bill an office/outpatient evaluation and management (E/M) service for this? Which CPT® codes apply to this situation?

Maine Subscriber

Answer: The answer will depend on what details are included in the documentation. When your ophthalmologist removes a foreign body (FB) from a patient’s cornea, you need to check whether she used a slit lamp to examine the eye. If the wood chips were removed without a slit lamp, you’ll likely report 65220-RT (Removal of foreign body, external eye; corneal, without slit lamp). If your ophthalmologist did use a slit lamp, the most appropriate choice would probably be 65222-RT (Removal of foreign body, external eye; corneal, with slit lamp).

Expert coding tips:

When submitting corneal FB removal claims, be sure to check for slit lamp use before coding the service.

Do not use modifier 51 (Multiple procedures). You can use codes 65220 and 65222 for the removal of a single FB or for multiple FBs. It would be inappropriate to charge separately for the removal of each FB.
One way that you could get paid for extra services rendered is to append modifier 22 (Increased procedural services) and briefly explain why the service was more involved in the operative note, but this does not always get reimbursed.

Append modifier RT (Right side) or LT (Left side) to indicate which eye was treated. When this procedure is performed on both eyes, Medicare prefers the use of modifier 50 (Bilateral procedure), whereas other payers may ask you to report each eye separately using RT/LT modifiers.

Generally, these surgical codes include an office visit. That means in most situations, it is inappropriate to bill both an office visit (992xx (Office or other outpatient visit for the evaluation and management …) or 920xx (Ophthalmological services: medical examination and evaluation …)) on the same day as a minor surgical code such as FB removal. The exception is when the office visit is unrelated to the surgery; then you can bill both by appending 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 office visit code.

Example: Your ophthalmologist sees a patient for a six-month glaucoma check, and during the exam, she happens to discover a FB that needs to be removed. In this case, it would be appropriate to bill for the established-patient exam with modifier 25 because the E/M service is significant and separately identifiable from the minor procedure performed the same day. You would use the glaucoma diagnosis code for the office visit and the FB diagnosis code for the FB removal.

Note: If the office visit’s diagnosis code is related to the diagnosis used for the minor surgery, it would not hold up in an audit. While medically necessary, if the physician performs the established-patient exam solely to confirm the need for the FB removal, you cannot separately bill for it.