Ophthalmology and Optometry Coding Alert

Question: A 27-year-old patient presented to the clinic stating that when he was mowing the lawn, a piece of wire flipped up and hit him in the right eye. After examination and testing, the physician diagnoses him with a right lower canalicular laceration and determines that emergency surgery is needed. Later that day, the patient underwent conjunctivorhinostomy with tube insertion. Tube removal was done in the office two months after the operation.

Can we bill both 99203 and the surgery, and what about the removal? What diagnosis codes should be submitted?

AAPC Forum Participant

Answer: Yes, you can bill both the evaluation and management (E/M) service and the surgery; just be sure to apply the appropriate modifiers. Report the operation using 68750 (Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent) appended with modifier RT (Right side). Note that you may be able to use -E4 (Lower right, eyelid) instead of -RT for some payers.

E/M: Bill 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the new patient E/M — make sure the documentation supports a low level of medical decision making (MDM) or an encounter lasting at least 30 minutes.

Key: CPT^® 68750 has a 90-day global period. Because the procedure’s global period is 90 days, you should submit 99203 with modifier 57 (Decision for surgery) to indicate that the E/M service prompted the major surgery. Modifier 57 tells the payer that they must process the claim for the E/M service instead of including it in preoperative services in the surgical package payment.

Tube removal: In this case, you should not bill the tube removal separately. It was done in the office within the 90-day global period and, thus, is considered part of postoperative care. If your ophthalmologist had removed the tube outside the 90-day period or it was removed by a physician in a different group, reimbursement would be included as part of the E/M or eye visit code.

Diagnosis roundup: Report the right lower canalicular laceration with S01.111A (Laceration without foreign body of right eyelid and periocular area, initial encounter). Include external causes code W22.xxA (Striking against or struck by other objects, initial encounter) to provide additional information about the accident that caused the laceration.