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Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
The key word here is separate. For example, what if the patient came in for her usual glaucoma checkup and asked the physician to look at the cut on her eyelid? The physician sutures the cut. In this case, you would use -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M.
The examination under anesthesia, code 92018 (ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete), was performed because the patient has Downs syndrome and was unable to cooperate during the fundus exam or suture. The primary diagnosis is the injury (i.e, 921.1, contusion of eyelids and periocular area), which makes the examination necessary to check for possible other serious ocular injury. Use 758.0 (Downs syndrome) as the secondary diagnosis for 92018. Your documentation must explain why these procedures had to be performed at the hospital.