Optometry Coding & Billing Alert

Question: I saw a patient yesterday who had a conjunctival foreign body. I billed 65205 and 92012. Then I saw an article that said I couldn't bill for both an office visit and the procedure on the same day. Is that true?

Minnesota Subscriber

Answer: Unless you find it necessary to do a history, exam and decision-making with the performance of the FBR, you should not code for and bill the exam (92012, Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) along with the foreign-body removal (65205, Removal of foreign body, external eye; conjunctival, superficial).

But if you think the patient requires a full workup to rule out other problems and you consider this to be medically necessary, you should code and bill both services. Whether or not to bill an E/M code depends on what the patient tells you. If the patient tells you his eye hurts, an office visit is needed to determine why. Document the exact complaint the patient has if you want to defend using an office visit and an FBR procedure together.

You may not get reimbursed for both services, however, if you don't follow the documentation, modifier and diagnosis coding requirements for reporting an E/M service and an FBR on the same day. If you document the FBR in the slit-lamp portion of the examination, the carrier may assume that the office visit service was an integral part of the minor procedure and therefore included in the payment for the procedure.

Solution: Be sure to document the history, exam and decision-making components of the E/M service in a separate, dated entry for the FBR. Choose an appropriate examination code depending on the documentation, and append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

Smart idea: Put your notes for the FBR on a special FBR form. Keep the notes for the office visit on a separate form.

Bottom line: If the patient comes in and points to the foreign body on his conjunctiva, the optometrist doesn't need an office visit to determine what to do. Any other symptoms, problems, or concerns to be addressed at the same visit will need an office visit. If the patient comes in and says he has pain in an eye and doesn't know why, then the optometrist will start with an office visit to determine what the cause of pain is. Once the optometrist determines the patient has a foreign body, the optometrist will need an additional and separate procedure. If you file the office visit and the foreign body procedure, then modify the office visit with the 25 modifier.