Ophthalmology and Optometry Coding Alert

Question: The doctor saw the patient in the office after she had fallen and cut her eye, which was swollen and bruised. The patient had Downs syndrome, and the doctor was unable to examine the fundus or to suture the wound, and the same day sent the patient to the hospital for an examination under anesthesia and suture of wound. Should we use a -25 or -57 modifier for the office visit, and what diagnosis can be used for the examination under anesthesia? The patient is Medi-Cal.

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Answer: In this case, you should attach the modifier -57 to the evaluation and management (E/M) visit. Use -57 to identify that the decision to perform the surgery 12051* (layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) was made during the initial E/M visit. The patient came in for the E/M visit because she had a cut eye, and this is why the 12051 was performed. Modifier -25 is used to identify a separate E/M service on the same day of a procedure.

The key word here is separate. For example, what if the patient came in for her usual glaucoma checkup and asked the physician to look at the cut on her eyelid? The physician sutures the cut. In this case, you would use -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M.

The examination under anesthesia, code 92018 (ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete), was performed because the patient has Downs syndrome and was unable to cooperate during the fundus exam or suture. The primary diagnosis is the injury (i.e, 921.1, contusion of eyelids and periocular area), which makes the examination necessary to check for possible other serious ocular injury. Use 758.0 (Downs syndrome) as the secondary diagnosis for 92018. Your documentation must explain why these procedures had to be performed at the hospital.