Optometry Coding & Billing Alert

Question: A new patient reports to the optometrist complaining of pain around his left eye. After performing a level-two E/M, the optometrist diagnoses dry eye syndrome and inserts punctal plugs into the patient's lower left eyelid. Should I use the same ICD-9 code for the E/M and the punctal plug code?

Mississippi Subscriber

Answer: You should report the E/M code along with an ICD-9 code for the patient's complaint, and the plug insertion with an appropriate ICD-9 code to represent the optometrist's diagnosis.

On the claim, report the following codes:

- 68761 (Closure of the lacrimal punctum; by plug, each) for the plug placement, along with modifier E2 (Lower left, eyelid) attached to indicate the plug's location

- 375.15 (Other disorders of lacrimal gland; tear film insufficiency, unspecified) linked to 68761 to represent the dry eye syndrome.

- 99202 (Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the E/M, with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to show that the E/M and procedure were separate services.