Ophthalmology and Optometry Coding Alert

Question: An established patient presents to the ophthalmologist with complaints of pain and vision trouble in her left eye. After performing an expanded history, a problem-focused exam, and medical decision making (MDM) of low complexity, the ophthalmologist finds a superficial foreign body (FB) in the patient's conjunctiva and another FB in the cornea. He removes the FBs without documentation to show use of the slit lamp for the corneal removal. How many CPT codes should I report for this encounter?

Tennessee Subscriber

Answer: You should be able to collect payment on three CPT codes in this example, if your documentation supports medical necessity and includes the proper documentation with diagnosis codes.

When the doctor removes foreign bodies from different sections of the same eye, you can report both removals. Your ophthalmologist performed a separate E/M service prior to the removals, so you should code for that as well. On the claim, report the following codes:

• 65220 (Removal of foreign body, external eye; corneal, without slit lamp) for the corneal FB removal
• 930.0 (Corneal foreign body) linked to 65220 to represent the FB
• 65205 (... conjunctival superficial) for the conjunctival FB removal
• 930.1 (Foreign body in conjunctival sac) linked to 65205 to represent the FB
• 99213 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problemfocused examination; medical decision making of low complexity) for the E/M
• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99213 to show that the E/M and FB removals were separate services 379.91 (Pain in or around eye) linked to 99213 to represent the patient's eye pain.

Watch for: If the E/M work was not considered significant and separate from the pre-operative work required to perform the foreign body removal, then the E/M is not separately billable. Documentation in the medical record must also support the medical necessity for the E/M service that is separately reported.