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Primary Care Coding Alert

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Eye Irrigation and E/M Services

Published on Fri Jan 01, 2010

Question: A new patient who had been taking down Christmas tree lights from his house the day before reports to the family physician (FP) with an irritated left eye. He says that one of the lights shattered while he was handling it, and he has been "wiping the eye out all day." The physician examines the eye area, and notes "undetermined particles and small foreign bodies, but cannot confirm glass ... could just be pieces of leaves or grass." Using saline irrigation, the physician cleans out the patient's eye and sends him home; no further tools are necessary. Is this an ocular foreign body removal (FBR), or is irrigation an E/M service? Colorado Subscriber Answer: This is a superficial conjunctival FBR, and it sounds as if an E/M also occurred. On the claim, report the following: • 65205 (Removal of foreign body, external eye; conjunctival superficial) for the FBR; • [...]
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