You need a team effort to ensure that coding and documentation is done correctly, and techs have a key role to play. Working side-by-side with physicians, techs can receive advice on diagnoses and procedures that will help when it comes to coding. And since techs write in the patients’ charts, they should know the rules of documentation. The quiz below, and the tips that follow, can help techs avoid some common errors.
Test Your Knowledge
1. A patient has had surgery and is returning within the postop period for a quarterly glaucoma evaluation. What code(s) do you use?
2. A patient presents for an exam, and gonioscopy is performed. Since he underwent an exam and a test on the same day, should you use modifier –25?
3. A trabeculectomy patient requires an injection of 5FU. If her return visit is within the 90-day global period, what code(s) and modifier(s) do you use?
4. A malignant eyelid lesion on the left lower lid is excised. The pathology report indicates additional tissue must be removed. On the seventh day of the postop period, a larger excision with skin graft is performed. What code(s) do you use?
5. Which, if any, of the following three CPT codes is considered a minor procedure by Medicare? A) 67930 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva, B) 68115 Excision of lesion, conjunctiva; over 1 cm, or C) 68760 Closure of lacrimal punctum; by cauterization; ligation or laser surgery.
6. A patient presents with redness, tearing and excessive blinking in her right eye after suffering a foreign body sensation for a day. The doctor removes two foreign bodies and asks her to return the next day for follow-up. You use CPT code 65222 removal of corneal foreign body with slit lamp for the first visit, but what about the return visit?
Answers and Tips
1. Use CPT code 9921X or 9201X for the appropriate level of exam and append modifier –24.
Tip: Most important, the first line of the patient’s chart note should not state “postop.” Furthermore, the diagnosis code must reflect the glaucoma condition, not the surgical diagnosis. To use modifier –24, your documentation must make it clear that the visit is unrelated to the surgery.
2. No. Modifier –25 is not needed in this case, but it would be if the test had been one that is bundled with the exam in the Correct Coding Initiative.
Tip: Incorrect use of modifier –25 could prompt the payer and, historically, the Office of Inspector General to audit your practice.
3. Use CPT code 68200–58–eye modifier for the subconjunctival injection and HCPCS code J9190 for the 5-fluorouracil.
Tip: Typically, four or more injections may be given several days apart. The injection code has a global period of zero days. You can repeat the above coding example for each day’s injection(s).
4. Use CPT code 14060–58–E2 if less than 10 cm; use 14061–58–E2 if 10.1 to 30 cm.
Tip: Payment is per session. If more than skin is being removed, consider CPT code 67800.
5. Medicare considers all three to be minor procedures.
Tip: The key is to identify a procedure’s global period. With Medicare, minor procedures are those that have either a zero- or 10-day global period; with non-Medicare payers, minor procedures have a zero-, 10- or even a 15-day global period. To know when it is appropriate to bill again, it is important to recognize the global surgical days.
6. Since CPT code 65222 has a zero-day global period, you can use the appropriate level of E&M or Eye Code for the return visit.
Tip: With CPT code 65222, coding is per eye, not per foreign body.