Ophthalmology and Optometry Coding Alert

Imbedded or superficial? Corneal or conjunctival? Answer before codingCoding for an ocular foreign-body removal (FBR) seems simple: The ophthalmologist finds the FB, removes it and sends the patient home.Not so fast: Knowing what happens during that encounter is vital to correct coding. You have to know the FB's specific location and the ophthalmologist's actions during the session before arriving at the proper code.Determine if FB Is Imbedded or SuperficialAn ophthalmologist can remove two distinct types of FBs from a patient's eye: a conjunctival FB or a corneal FB. For conjunctival FBRs, coders need to know if the FB was superficial or embedded because the code choice will hinge on this information.If the ophthalmologist removes a superficial conjunctival FB, code the service with 65205 (Removal of foreign body, external eye; conjunctival superficial). If the ophthalmologist performs removal of an embedded FB from the conjunctiva, choose 65210 (... conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating) instead.How can I tell? Your surgeon may also refer to a superficial FB in encounter notes as a "loose" FB. "A superficial FB usually sits on the surface (of the conjunctiva), whereas an embedded FB is just that: embedded," says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla."For a superficial FBR in the conjunctiva, a doctor uses something simple, like a moistened, sterile Q-tip; this works very well with larger FBs, such as dirt particles or ash," Martien says.With embedded FBRs, the ophthalmologist may use a cotton swab for the procedure, but the doctor may also have to scrape out the FB area with a needle. Embedded conjunctival FBRs sit in the conjunctiva but have not penetrated the anterior chamber.You code it: A house painter with a swollen left eye reports to the ophthalmologist. The doctor examines the patient and finds a paint chip sitting atop the patient's conjunctival sac. Using a moistened swab, the doctor removes the FB.On the claim, you should report the following:• 65205 for the superficial FBR.• 930.1 (Foreign body in conjunctival sac) to support medical necessity for the procedure.Change Code Sets When Reporting Corneal FBRsLike conjunctival FBRs, corneal FBRs have their own code set. Although the difference between 65205 and 65210 is the FB's location, corneal FBR codes are separated by slit-lamp use. The doctor might need to use a slit lamp for visualization of hard-to-see corneal FBs.In a nutshell: When the ophthalmologist removes an FB from the cornea, you'll need to check the op note to determine the approach and method of removal before you choose a code. If the doctor removes an FB from a patient without using a slit lamp, report 65220 (... corneal, without slit lamp). When the doctor needs to [...]