By Anthony P. Johnson, MD, AAOE Board Member, and Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
Despite ophthalmology’s best efforts to educate the public about eye safety, you won’t have to wait long for the next ocular injury. Get prepared with EyeNet’s two-part series on coding for eye injuries featuring a list of CPT codes that only commercial payers use (see Part 1, June), three case studies (one in Part 1 and two below), and web extras below.
Case #2: A Bad Day at Work
During his first day on the job at a home improvement store, 18-year-old Blake* cut the metal band around layers of stacked wood. The metal band sprang toward his face, lacerating it from cheek to forehead, including his left eye. Blake’s manager drove him to the closest hospital ER. The ER physician closed the skin laceration, packed the left eye with antibiotic ointment, and applied a pressure patch to that eye. Blake was told to see an ophthalmologist “first thing in the morning for severe corneal abrasion.”
The next morning, when staff arrived at the practice, Blake and his mother were already at the office door. Blake, who is an established patient at the practice, was in terrible pain and felt nauseated.
Staff action. The technician took Blake to the exam room and, per HIPAA requirements, she asked him if his mother could join them. The technician obtained the name of Blake’s employer and manager and gave that information to the front-office staff so they could call for an injury report, as this was a workers’ compensation claim. The front-office staff notified scheduled patients that there was an emergency and, if they were unable to wait, offered to reschedule their appointments.
Exam and history. Blake’s uncorrected visual acuity (VA) in the right eye was 20/25. In order to obtain the VA of the left eye, she needed to remove the patch. But when she did so, she saw that the eye looked “flat,” which made her wonder why a pressure patch had been applied (it was unknown whether the ER doctor had requested an ophthalmology consult). She reclined Blake’s chair, instructed him not to touch his face, and immediately got a physician. Seven exam elements were performed, but—because of the trauma—the physician was unable to obtain the other five elements. In such circumstances, credit is still given for those elements (but only if they were considered medically necessary). A mental assessment was performed as the 13th element of the exam. An exam that includes that 13th element is considered comprehensive. The technician had obtained a comprehensive history from Blake. The level of medical decision-making reached the high-complexity threshold.
CPT codes. The practice submitted CPT code 99215–57 for the exam, with modifier –57 indicating that this office visit was used to determine the need for surgery. The practice can also bill CPT code 99058 Emergency disrupting office hours (99058 is from a family of codes that can’t be used for Medicare or Medicaid, as discussed in Part 1 of this series).
Diagnoses. ICD-10 codes: S05.22XA Ocular laceration with prolapse or loss of intraocular tissue, left eye, initial encounter and W22.8XXA Striking against or struck by other objects, initial encounter.
Post-op. During the postoperative period, Blake was fitted for a bandage contact lens. The practice billed for this using CPT code 92071 Fitting of bandage lens and HCPCS code V2599 Supply of bandage lens.
After the eye had healed, Blake was referred to a cornea specialist, as a corneal transplant would eventually be needed. In order to bill a workers’ compensation claim for the transplant, that specialist would need a corneal transplant diagnosis plus S05.32XS Corneal laceration without prolapse or loss of intraocular tissue, left eye, indicating sequela.
* Patient name is fictitious.
ICD-10 Tips for Eye Injuries
There are plenty of ICD-10 accident codes—such as W53.22, for being struck by an orca (killer whale)—but are they required when you treat an eye injury? It depends. Workers’ compensation insurance may require that you use those codes, but the patient’s commercial health insurer is less likely to require them. Indeed, the added detail that those codes provide may tempt the patient’s commercial health plan to try and pass the financial obligation off to another insurer, such as the patient’s homeowner insurance.
Sequela ICD-10 codes, which end in an S, are not always recognized by nonworkers’ compensation payers. Better to report ICD-10 codes with an A or a D in the last position.
Checklist—Ensure That Your Front Office and Billers Are Prepared for Patients With Eye Injuries
First, stay calm! Especially when others around you are not.
Four general steps. Does your practice have the following?
◻ Time slots in the daily schedule that are reserved for semiurgent surgery.
◻ Medical equipment that is readily available.
◻ A written policy for handling emergencies.
◻ Staff training for handling emergencies.
Phone protocol. Does your emergency phone protocol include the following?
◻ Telephone triage protocol. This should be available for all who answer the phone, including the answering service. (A sample triage screening protocol is available at aao.org/practice-management/coding/updates-resources.)
◻ Preauthorization checklist. This is especially important for an after-hours emergency. Note: If you perform surgical correction in-office, you should confirm that office-based surgery is payable when you obtain preauthorization.
◻ Requirement to request payer information. Determine who the payer will be:
- Patient’s personal insurance?
- Workers’ compensation insurance for a work-related injury?
- Auto insurance? (Bill the patient and the patient collects from auto insurance.)
- Homeowner insurance? (Bill the patient and the patient collects from homeowner insurance.)
◻ Requirement to request an incident report (when one is needed). For eye injuries, the No. 1 reason for delay in payment is failure for employer/employee/patient to file an incident report.
Use OMIC’s Resources. Download OMIC’s telephone screening toolkit at www.omic.com/telephone-screening-of-ophthalmic-problems-sample-contact-forms-and-screening-guideline/.
Case #3: A Bad Sports Day
Kyle* was hit in the left eye with a soccer ball. The eight-year-old immediately complained of decreased vision and was taken to see his uncle, a retina specialist.
Exam and history. Visual acuity was 20/200 in his right eye and 20/20 in his left. A comprehensive history was obtained and documented. A dilated comprehensive exam revealed that there was no blood in the anterior chamber or vitreous, but there was commotio retina involving the macula.
The plan. Monitor patient closely and ask him to return after one week, or earlier if need be.
CPT code for initial exam. The practice can either submit E&M code 99203 or Eye visit code 92004.
Diagnoses. ICD-10 codes: S05.92XA Unspecified injury of left eye and orbit, initial encounter and W21.02XA Struck by soccer ball, initial encounter.
One week later. When Kyle returned to the office, the commotio retina had resolved, but his visual acuity was only 20/100. Optical coherence tomography (OCT) of the macula revealed a partial thickness macular hole.
CPT codes for second exam. Bill for the exam and submit CPT code 92134 for the OCT.
Diagnosis. ICD-10 code: H35.342 Macular cyst, hole, or pseudohole, left eye.
The rest of the story. Kyle was seen for five visits over the next two months. His vision improved to 20/40, but he still had residual distorted vision due to the partial-thickness hole. Kyle is now at risk for glaucoma.
When you look after relatives. In this case, the patient was the physician’s nephew. Does this impact billing? Physicians can’t bill for services that they provide to certain family members—but it is OK to bill for providing care to your nephew.
According to the CMS SMC Transmittal 2332, physicians can’t bill for services they provide to family members. Commercial payers agree with this rule too. Who exactly is a family member according to the payers? The following degrees of relationship are included within the definition of immediate relative:
- Members of your household
- Domestic partners
- Your husband or wife
- Your natural or adoptive parent, child, or sibling
- Your stepparent, stepchild, stepbrother, or stepsister
- Your grandparents, grandchildren, or their spouses
- Your father-in-law or mother-in-law
- Your sons-in-law or daughters-in-law
A brother-in-law or sister-in-law relationship does not exist between a physician and the spouse of his wife’s (her husband’s) brother or sister. A father-in-law or mother-in-law relationship does not exist between a physician and his/her spouse’s stepfather or stepmother.
A step relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or through the death of one of the parties. Thus, for example, if a physician treats his stepfather after the death of his natural mother or after the stepfather and natural mother are divorced, or if he treats his father-in-law or mother-in-law after the death of his wife, the services are considered to have been furnished to an immediate relative and are excluded from coverage.
SOURCE: http://www.sccma-mcms.org/Portals/19/assets/docs/Physician-treating-family-member.pdf. Accessed May 10, 2019.
* Patient name is fictitious.