Ophthalmology and Optometry Coding Alert

Question: A patient returns for follow-up. The provider notes improvement in the meibomian gland dysfunction (MGD) affecting the upper and lower lids of both eyes with eyelid scrubs and hot compresses. On exam, the ophthalmologist flips each lid, presses on them, and is able to express some fluid. The patient is to continue scrubs and compresses. The patient’s keratoconjunctivitis sicca is not improving with the use of artificial tears. The doctor decides to insert surface mount plugs into the puncta on both lower lids. The patient is instructed to continue Cyclosporin 0.05% BID OU and return in a week. How is this coded?

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Answer: You should first check that your chart note supports billing the evaluation and management (E/M) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure …). Every procedure has a small E/M component built into it to represent the preoperative work associated with rendering a procedure. The documentation must show the provider performed a significant, separately identifiable service from the procedure that was medically necessary.

E/M: Report the appropriate exam code ((9921x (Office or other outpatient visit for the evaluation and management of an established patient …) or 9201x (Ophthalmological services: medical examination and evaluation …)) with modifier 25 appended for the MGD care.

Diagnosis roundup 1: Use H02.88A (Meibomian gland dysfunction right eye, upper and lower eyelids) and H02.88B (… left eye, upper and lower eyelids) as the diagnoses associated with the E/M.

Minor procedure: Submit a single line on the claim for 68761 (Closure of the lacrimal punctum; by plug, each) with modifier 50 (Bilateral procedure) or report each eye separately on the claim with modifiers -RT (Right side) and -LT (Left side).

Diagnosis roundup 2: Be sure to include H16.223 (Keratoconjunctivitis sicca, not specified as Sjogren’s, bilateral) as the associated diagnosis for the minor procedure, 68761.

Tip: A procedure note is necessary to support the minor surgery. You don’t have to write the notes on a separate sheet, but visually separating the exam from the procedure will help show an exam that is separately reimbursable.