Optometry Coding & Billing Alert

Question: A 16-year-old boy presented with a scratchy sensation from a foreign body in his left eye. The optometrist examined him and found sawdust resulting from cutting firewood. No serious damage or laceration of the cornea resulted. Lacking a serious outcome, which diagnosis code should I use?

Virginia Subscriber

Answer: To select the proper diagnosis code, you need to refer to the documented patient complaint if the optometrist did not make a definitive diagnosis.

In this case, the physician identified the source of the problem -- a foreign body (FB) -- so you should report 930.0 (Corneal foreign body).

If the optometrist had not located a foreign body, you would have had to report codes for the patient's symptoms, for example, 379.91 (Pain in or around eye) or 379.93 (Redness or discharge of eye).

CPT code: If the doctor removes a corneal FB from a patient without using a slit lamp, report 65220 (Removal of foreign body, external eye; corneal, without slit lamp). When the doctor needs to use a slit lamp for the FB removal, opt for 65222 (... corneal, with slit lamp).

Depending on the details, you may also be able to report an E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. If the patient knows he has something in his eye, however, just report the FB removal code alone because you would not need an office visit to determine the need for the FB removal.