Ophthalmology and Optometry Coding Alert

Question: A patient presented to the clinic complaining of foreign-body sensation and irritation in the right eye. She is s/p YAG laser capsulotomy and is still in the global period for the procedure. The ophthalmologist examined the patient, arrived at a diagnosis of trichiasis, and performed epilation with forceps to remove lashes from the lower right lid. What codes and modifiers would I use in this case?

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Answer: The key to correctly coding this visit is recognizing two things:

• You’re in the global period of the YAG capsulotomy, coded with 66821 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages)), and
• The office visit is related to the minor surgery — it’s not a significant, separately identifiable evaluation and management service (E/M).

Do this: For the lash epilation, report 67820 (Correction of trichiasis; epilation, by forceps only). CPT^® code 67820 represents “a minor procedure with a 0-day global period, therefore, minor surgery billing rules apply to the exam on the same day. In this case, you cannot bill for the exam, as there was no significant, separately identifiable E/M service,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Next: Append modifier 79 (Unrelated procedure or service by the same physician … during the postoperative period) to the epilation code to show that the minor procedure is not related to the YAG postoperative period and that it was not a complication. Boost specificity by also adding modifier E4 (Lower right, eyelid) to 67820 to identify the eyelid.

Diagnosis roundup: For trichiasis of the right lower eyelid, report H02.052 (Trichiasis without entropion right lower eyelid).

Putting it all together, you’d code for the ophthalmologist’s services as 67820-79-E4 and H02.052 for the diagnosis of trichiasis, which will help support medical necessity of the procedure.

New code alert: You’ll soon have new ICD-10 codes available to report an ocular foreign body (FB) sensation. Starting Oct. 1, 2023, when a patient complains of FB sensation in the right eye and the cause of this symptom is unknown, you’ll report the patient’s problem with H57.8A1 (Foreign body sensation, right eye). Keep in mind, once the provider determines the cause of the FB sensation, you’ll use the code that best represents the condition diagnosed.