Primary Care Coding Alert

Question: After injuring his eye on the job, a patient presents to a family physician for eye pain. The FP sees the patient on an emergency basis and performs a level-two new patient exam.
 
The physician administers local anesthesia and a fluorescein strip to the eye. With a Wood's lamp illuminating the eye, the FP finds a corneal abrasion. He then washes the eye, places a patch and writes the patient a prescription. May I report 92230 for the fluorescein stain?

Kansas Subscriber

Answer: No. Code 92230 (Fluorescein angioscopy with interpretation and report) involves injecting the dye into the arm, rather than dipping a strip into the eye. You should instead include the fluorescein stain in the E/M service (99202, Office or other outpatient visit for the evaluation and management of a new patient ...).
 
Tip: Because the FP sees the patient on an emergency basis, remember also to report 99058 (Office services provided on an emergency basis). You should also use a corneal abrasion diagnosis of 918.1 (Superficial injury of eye and adnexa; cornea) and the appropriate E codes that describe the accident.

 - Answers to You Be the Coder and Reader Questions provided and/or reviewed by Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa.; and Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.