Optometry Coding & Billing Alert

Question: I had a patient with eye pain and I found a lash that was irritating the cornea. I removed the lash with forceps. Are we able to charge for an exam if I did a history, acuities, and slit lamp in the process of finding the lash that was causing the problem?

Arkansas Subscriber

Answer: Yes, you can and should bill for the exam. The complaint justifies examining the whole eye, even if you only found and treated trichiasis. You can report  the ophthalmic exam code or the appropriate level of E/M visit and append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). You should also report 67820 (Correction of trichiasis; epilation, by forceps only).

You must document the history, exam and medical decision-making involved in the E/M service first and then do a dated entry for the procedure.
 
Remember: Even though the expanded definition of modifier 25 states that the diagnosis can be the same for the office visit and the procedure, two separate diagnoses may help clarify for the payer that the office visit is separate from the procedure. If the symptom that brought the patient in for the office visit is linked to the final diagnosis of the procedure, you often find that there are two separate diagnoses.
 
In your example, link the exam or office visit (with modifier 25) to 379.91 (Unspecified disorder of eye and adnexa; pain in or around eye), and link 67820 to 374.05 (Other disorders of eyelids; trichiasis without entropion) or 374.00-374.04 (Entropion and trichiasis of eyelid) for one of the trichiasis-with-entropion diagnoses. In your notes, use two separate pages (or at least two separate paragraphs) to describe the exam and the procedure - be sure to sign and date both.