Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist removed a foreign body from a patient’s eye. Can we also report an E/M service in addition to the foreign body removal code (such as 65205 (Removal of foreign body, external eye; conjunctival superficial).

New Mexico Subscriber

Answer: Version 22.1 of the Correct Coding Initiative (CCI) does bundle the E/M codes (such as 99212-99215) into 65205, but you can separate the edit with a modifier.

If, for instance, the physician found it necessary to obtain history, perform an exam (either prior to the foreign body removal or afterward) with medical decision making, you should report the appropriate level of E/M service. The physician must document the circumstances that support medical necessity for the level of E/M service performed that was in addition to the procedure. Make sure that if you completely separate the documentation for the FBR from the E/M that there’s still enough in your records to support the E/M code the doctor circled.

Documentation tip: Be sure to document the history, exam, and medical decision making components of the E/M service in a separately identifiable medical record entry. You also need a procedural note separately documented for the FBR, and be sure that the ophthalmologist has signed and dated both sections. Choose an appropriate E/M code depending on the documentation and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to this exam code.