Ophthalmology and Optometry Coding Alert

Question: A patient had a metallic foreign body removed from his eye by a different physician. The patient came to us saying he still felt a foreign-body sensation. We discovered a rust ring and removed it. Can we charge a removal code, or just an office visit?  

Tennessee Subscriber
 
Answer: Use 65435* (removal of corneal epithelium; with or without chemocauterization [abrasion, curettage]) with diagnosis code 998.89 (other specified complications). You can also bill for an E/M office visit (99201-99215) or eye procedure (92002-92014) if you have documented a significant and separately identifiable office visit. Append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit code.