Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist saw a patient in the morning who complained of a foreign body (FB) in her right eye after chopping wood. The physician removed the wood chip from the patient’s conjunctiva. Later that day, the patient was chopping wood again and got another FB in her right eye — this time affecting the sclera but not perforating it. Which codes should we report in this situation?

Texas Subscriber

Answer: Because the services were performed at different encounters on the same date, it’d be appropriate to use a modifier to report the two separate procedures. Here are your options for coding the FB removals:

• For payers who do not recognize the X{EPSU} modifiers, code these services as:

o 65210 (Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating)

o 65205-59 (Removal of foreign body, external eye; conjunctival superficial)

• For payers, such as Medicare Part B, UnitedHealthcare, and some BCBS payers who recognize the X{EPSU} modifiers for separate procedures, report the FB removals with:

o 65210

o 65205-XE

Reasoning: Use modifier XE (Separate encounter, a service that is distinct because it occurred during a separate encounter) when it is recognized because payers are monitoring the use of modifier 59 (Distinct procedural service) and red-flagging high usage for audit. Reporting the X{EPSU} modifiers shows payers that the practice knows why and has the documentation to clinically support the unbundling that is present on the claim, whereas using modifier 59 may cause a payer to consider that the practice is trying to unbundle without justification and the appropriate documentation.

Coding tip: When your ophthalmologist performs a FB removal, check to verify the exact location of the FB before selecting a code. In cases where the physician removes a FB from the surface of the conjunctiva, the membrane covering the eye, look to 65205. If the doctor removes a foreign object embedded in or below the conjunctiva or in the sclera (without perforation), use 65210 to report the service.

What’s the difference? A superficial FB is when an object becomes lodged on the surface of the bulbar or the palpebral conjunctiva and is generally easily removed with a cotton swab, tweezers, or irrigation; whereas embedded FBs extend into the conjunctiva and may even be located below the membrane (subconjunctival) or in the sclera, the outer covering of the eyeball. In these cases, the physician will likely use a needle or an instrument called a spud to dislodge the FB, and the spud or tweezers to capture it. The deeper the FB is, the more likely a needle will be needed to dislodge it.