Revenue Cycle Insider

Question: A patient was working under their car when a fragment of metal fell from the engine and hit them in the left eye. The patient experienced immediate pain, blurred vision, and photophobia (sensitivity to light) and went directly to the emergency department (ED). A slit lamp exam is performed, including application of a fluorescein strip to confirm the location of injury. The ED physician finds a shard of metal lodged in the left cornea, above the iris and near the pupil. The physician removes the foreign body (FB) at the slit lamp with forceps, and prescribes the patient erythromycin ointment to prevent or manage any resulting infection or irritation. Encounter notes indicate that the physician performed moderate-complexity medical decision making (MDM) during the evaluation and management (E/M) preceding the foreign body removal (FBR). What codes should I report for this encounter?

Illinois Subscriber

Answer: As long as there is evidence of a significant, separately identifiable ED E/M service, you can report an ED E/M along with the FBR code. If the E/M is minor or incidental to the FBR, then you cannot report it separately.

You state that there was a separate E/M; just check the notes to be sure that’s the case before filing.

Then, you can report:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99283 to show that the ED E/M and FBR are significant, separately identifiable services
• 65222 (Removal of foreign body, external eye; corneal, with slit lamp) for the FBR
• Modifier LT (Left side) appended to 65222 to indicate laterality
• T15.02XA (Foreign body in cornea, left eye, initial encounter) appended to 99283 and 65222 to represent the patient’s injury — provided the separate E/M involved the FB

Exception: If there was a separate ED E/M that did not involve the FBR, then you should choose a different ICD-10-CM code for the E/M.

Christine Killeen CPC, CPC-M, CPB, CPMA, COPC, Contributing Writer