Ophthalmology and Optometry Coding Alert

If you don't know the difference between coding traumatic injuries treated in the office and in the emergency room, you could receive a blow to your reimbursement-ego the next time your ophthalmologist treats a firecracker burn. Coding traumatic eye injuries depends on two factors: where the treatment was rendered and when the treatment was rendered. Choose CPT codes by 'Where'and 'When' Ophthalmologists provide traumatic eye injury treatment in two primary locations the office and the emergency department. Let's suppose a 14-year-old boy is brought to the ophthalmologist's office complaining of a scratchy sensation from a foreign body in his left eye. The ophthalmologist examines the patient and discovers sawdust from a woodshop project to be the source of the discomfort. Luckily, there is no serious damage or laceration of the cornea. To code this procedure, choose the applicable E/M code (99201-99215) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Next choose an appropriate foreign-body removal code, 65205-65222, depending on the operative documentation.

You can also report code 99058 (Office services provided on an emergency basis), which can be found in the Medicine section of CPT, to indicate that the patient presented in the office on an emergency basis, says Lisa A. Bridges, CPC, ophthalmology coder with Woodhams Eye Clinic in Atlanta, "but not all payers necessarily recognize and reimburse for 99058."

For a Medicare patient, you would have coded the office visit with modifier -25 as well as the foreign-body removal if the E/M service was separately identifiable and sufficiently documented. Medicare doesn't recognize 99058 and won't pay more for in-office emergency treatments, so leave 99058 out of your in-office emergency service claims, Bridges says. In other words, you can't bill the patient separately for the emergency, after-hours or weekend charge, even if you obtain an advance beneficiary notice (ABN). In many cases, patients presenting with traumatic eye injuries file under workers' compensation, says Diane Gleason, CPC, ophthalmology coder with Cadillac Eye Clinic in Mich. If it is a new episode and a new patient, she bills an office visit code with modifier -25 and the procedure code representing the surgical service rendered, she says. "Typically the evaluation and management service we bill is a low-level code, 99201 or 99202, for example," when the physician takes the patient's history and meets the documentation requirements for a separate E/M service.

The reasoning: When a patient is seen on an emergency basis, the physician is more likely to perform a "problem-focused" or "expanded problem-focused" examination of the area of injury or complaint, says Raequell Duran, president, Practice Solutions, Santa Barbara, Calif. For workers' compensation patients, Gleason [...]