Ophthalmology and Optometry Coding Alert

Eye injuries sustained on the job may require the ophthalmologist to bill a workers' compensation carrier. But, sometimes patients present with a work-related injury and a nonwork-related injury. Coders must know how to split-bill and document these cases to ensure adequate and ethical reimbursement.

State boards oversee workers' compensation carriers, which use CPT codes for claims, explains Cam Teems, senior consultant for Gates, Moore, an Atlanta-based medical consulting firm. "Most health plans won't pay for a work-related injury," Teems says. "Instead, that payment is covered by workers' compensation."

In most states, if an employee is injured at work, he or she is directed to a panel of physicians who have contracted to take workers' compensation cases. A physician who serves on such a panel generally agrees to the rates and code bundles of the workers' compensation carrier.

If a physician isn't enrolled with workers' compensation and a patient presents with a work-related injury, the physician may have difficulty getting paid, Teems says. "The best thing you can do if you're not contracted is to refer the patient, if stable, to the emergency room or to a physician who is contracted." Take Code-Specific Notes Keep separate notes for each kind of code injury versus non-injury if you split-bill, recommends Melissa K. Duchak, CPC, an ophthalmology coding consultant based in Piscataway, N.J. The following examples illustrate how to split-bill workers' compensation cases:

A patient comes in with a minor corneal abrasion (918.1, Superficial injury of eye and adnexa; cornea) caused by flying dust and debris on the job. The physician examines the patient, billing a lower-level E/M service (99201-99202, 99212-99213) for the anterior segment exam. The patient states that before the current problem with the dust and debris, he had vision problems and requests a complete eye examination to determine the cause. Bill the vision portion of the visit with an eye code (most likely 92002) unless there is justification to repeat all parts of the eye examination, Duchak says. If the patient has a medical condition such as cataracts, link the 920xx code to the diagnosis code for cataract (366.xx). File the injury claim with workers' compensation, and the eye code claim with the patient's private insurance. Note: Your computer system may have trouble filing one patient to two plans; be prepared to file manually. A patient presents with a complaint of a foreign-body sensation after walking past a renovation work area, but no foreign body is found. In fact, the foreign-body sensation has dissipated since the employee left the workplace. The patient also states that she hasn't been seeing well while driving at night and, since she hasn't been to an ophthalmologist in years, wants it checked. In this case, [...]