Ophthalmology and Optometry Coding Alert

Question: An established patient presents to the ophthalmologist with complaints of pain and vision trouble in her left eye. After performing an expanded history, a problem-focused exam, and medical decision making (MDM) of low complexity, the ophthalmologist finds a superficial foreign body (FB) in the patient's conjunctiva and another FB in the cornea. He removes the FBs without documentation to show use of the slit lamp for the corneal removal. How many CPT codes should I report for this encounter?Tennessee SubscriberAnswer: You should be able to collect payment on three CPT codes in this example, if your documentation supports medical necessity and includes the proper documentation with diagnosis codes.When the doctor removes foreign bodies from different sections of the same eye, you can report both removals. Your ophthalmologist performed a separate E/M service prior to the removals, so you should code for that as well. On the claim, report the [...]