Ophthalmology and Optometry Coding Alert

Frequently, ophthalmologists spend a lot of time searching a patients eye for foreign material. But how do they bill for the procedure when nothing is found?

If you didnt remove anything, you cant bill for that procedure, says Melodie Aeder, network manager for Andersen Eye Associates of Saginaw, MI. You would have to use an evaluation/management code. The level code you use would depend on the history, the extensiveness of the exam and the level of decision-making involved.

If theres no foreign body, you cant bill for removing it, concurs Pat Steingass, insurance coordinator for Spectrum Eye Care of Findlay, OH. But that doesnt mean you wont get paid for the visit. There are a lot of problems that can cause the sensation of a foreign body.

Examples of problems that cause the patient to feel as if a foreign body is in the eye include corneal abrasion, allergies, dry eyes, edema, laceration, stye and corneal erosion.

Janet Meyers, office manager for Francis D. Trotta, MD, of Boise, ID, recommends that the ophthalmologist document the amount of time involved in such a visit.

You probably will be doing an expanded office visit (99213) for this kind of problem, she says. Its not unusual for the doctor to spend some time looking for the cause.

In a way, its easier if the doctor finds a foreign body right away. Trying to determine what is responsible for the sensation can actually be more time-consuming than removing it.