Ophthalmology and Optometry Coding Alert

Question: A patient came to our office for severe right eye pain, sensitivity to light, and decreased vision in the same eye. My ophthalmologist performed a gonioscopy, serial tonometry, and laser peripheral iridotomy. Can I report all of these procedures plus the office visit?

North Dakota Subscriber

Answer: There aren't any Correct Coding Initiative (CCI) edits bundling the codes for these procedures. You should report all three and the appropriate E/M code.

Report the iridotomy first (because it has the highest relative value) using 66761 (Iridotomy/iridectomy by laser surgery [e.g., for glaucoma] [one or more sessions]). Attach the appropriate eye modifier to tell the payer which eye your ophthalmologist worked on.

Next, report the E/M visit using the appropriate new patient (99201-99205) or established patient (99211-99215) office visit code -- for a new patient in this case you'll likely report 99204 or 99205, based on the documented service level. Append modifier 57 (Decision for surgery) to the E/M code to indicate that your ophthalmologist made the decision for surgery during this visit and you should be separately paid for it.

Last, you should report 92100 (Serial tonometry [separate procedure] with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day [e.g., diurnal curve or medical treatment of acute elevation of intraocular pressure]) for the serial tonometry and 92020.