Optometry Coding & Billing Alert
Use Caution With FB Removal and E/M
Question:
Alabama Subscriber
Answer:
No. Based on the information you provided, payers will consider the service your optometrist performed to be part of the foreign body (FB) removal.Why? You should code a separate E/M service only if the physician has to perform a separate E/M to assess another problem, or a separate E/M was medically necessary prior to performing the FB removal.
Determining the foreign body's location in the patient's eye is an integral part of the procedure, and payers include that service in the removal procedure.
You're correct that you should report the FB removal with an FB procedure code. In this case, report 65205 (Removal of foreign body, external eye; conjunctival superficial) linked to 930.1 (Foreign body in conjunctival sac).
If your optometrist performs a separate E/M service to evaluate another problem or condition, there must be separately identifiable documentation in the medical report to support both the service level rendered and medical necessity for the additional work separate from the FB removal. Then, you would report the appropriate E/M service level (99211-99215) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
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