Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmologists uses a slit-lamp to check on healing after a foreign-body removal during follow-up visits. He wants to try to charge extra for using the slit-lamp, arguing that it takes additional time and expertise to do this. Granted, he used it the first time for the FB removal, but it seems a bit much to try to charge extra each time. How should we code and bill these types of visits?

North Dakota Subscriber

Answer: There is no code that describes only a slit-lamp exam without a removal of a foreign body. If the ophthalmologist performs the exam as part of a follow-up encounter to evaluate the patient'scondition, only a low-level E/M code (99212) might be correct.

Link 99212 to the original complaint -- for example, 918.1 (Superficial injury of the eye and adnexa; cornea). If the patient presented with pain or other symptoms that necessitated more care and management, a higher level E/M code might be appropriate if supported by the documentation.

But if the ophthalmologist examines the eye as part of the follow-up care of foreign body removal -- even with the slit lamp -- a low level E/M visit might be appropriate and is appropriate to bill since there are no global days associated with the previous foreign body removal CPT procedure codes 65205-65222.

Always check the global days of the procedure the physician performed to determine if follow-up care is included. Some patients might not be very happy to pay another office visit copay for care they feel should be part of the procedural service. Remember that patient copays are not based on the level of E/M service and they would need to pay the same copay amount regardless of the level of E/M service.

--Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.