Optometry Coding & Billing Alert

Question: An optometrist removes a foreign body in a patient's cornea with the help of a slit lamp and performs a level-three E/M service to check for further injury. What codes should I use for this encounter?

Nebraska Subscriber

Answer: You'll report both the E/M and the foreign body removal (FBR) using separate CPT codes:

• Use 65222 (Removal of foreign body, external eye; corneal, with slit lamp) for the FBR.

• Report 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...) for the E/M service.

• Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99203 to show that the E/M was indeed a significant and separate service from the FBR.

• Link 930.0 (Foreign body on external eye; corneal foreign body) to 65222 and 99203 to prove medical necessity for the encounter.

Caution: The physician's use of a slit lamp impacts the codes that you use. If the doctor performs corneal FBR without using a slit lamp, you should report 65220 (... corneal, without slit lamp) instead of 65222.