By Anthony P. Johnson, MD, AAOE Board Member, and Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
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Many practices treat eye injuries on a weekly, if not daily, basis. Make sure you are coding them appropriately by reviewing this two-part series, which includes one case study below and two more next month.
Check your commercial payers’ policies on the 99050-99060 family of CPT codes. Some commercial payers will reimburse you for the codes listed below in addition to the appropriate level of E&M or Eye visit code. First published in 1993, these codes were initially designed for workers’ compensation emergency visits.
99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed, (e.g., holidays, Saturday or Sunday), in addition to basic service
99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
99053 Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service
99056 Service(s) typically provided in the office, provided out of the office at request of patients, in addition to basic service
99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service
99060 Service(s) provided on an emergency basis, out of office, which disrupts other scheduled office services, in addition to basic service
Commercial payers may cover some of the above codes but not others. For each of these six codes, a commercial payer’s policy may be to 1) pay for it (though there may be conditions that need to be met), or 2) indicate that payment is the patient’s responsibility, or 3) state that it is included in the exam per CMS policy. For example, some commercial plans may cover CPT code 99050 “ … in situations that would otherwise require more costly urgent care or emergency room settings … .”
Some commercial payers reserve Eye visit codes for vision exams. For these payers, consider reporting the appropriate level of E&M code when evaluating injuries. The E&M codes also should be considered when MD-patient face-to-face time is a factor.
Don’t bill codes 99050-99060 to Medicare Part B or Medicaid. They are factored into the payment of the exam.
Case #1: A Mowing Mishap
When 11-year-old Ronnie* was mowing the lawn, a piece of wire “flipped up” and hit him in the right eye.
Exam. There was a right lower canalicular laceration.
Staff action. Staff told the ambulatory surgery center to add an emergency case that night. They also contacted the insurance company for authorization of three possible surgical codes: For conjunctivorhinostomy, there are two CPT codes, depending on whether or not a tube is inserted (68750 and 68745, respectively); a third option was 68700 Plastic repair of canaliculi. First thing the next morning, staff got back in touch with the insurance company to confirm that they could bill 68750 for surgery with tube insertion.
Documentation. Ronnie’s chart documented the following: comprehensive history, obtained through his mother; all 12 elements of the exam, through dilated pupils, plus mental assessment; and low-complexity medical decision-making.
CPT codes. The practice billed 99203–57 for the eye exam and 68750–RT for the procedure.
Modifiers. Because the procedure has a 90-day global period, modifier –57 was used to indicate that the exam was performed to determine the need for the major surgery. As not all commercial plans recognize –E4 Lower right lid, modifier –RT was used.
Diagnoses. ICD-10 codes: S01.111A Laceration without foreign body of right eyelid and periocular area and W228.XXA Striking against or struck by other objects, initial encounter.
The rest of the story. Tube removal was done in the office within the 90-day global period and was considered part of the postoperative care. If it had been removed outside that 90-day period or removed by a different physician, it would have been considered part of the E&M or Eye visit code.
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* Patient name is fictitious.