Each year, as the days get longer and warmer, there is a renewed interest in outdoor activities, which can cause a spike in sports-related eye trauma. To see if you’re ready to document and code those injuries, tackle 2 case studies—1 below and another online.
This 20-year-old woman was seen in an emergency department (ED). The ophthalmologist saw her after she had been treated by an ED physician.
Chief complaint. While using an automated “toss back” machine to practice catching a rapid succession of softballs, at 2 p.m. the patient was struck in the right eye by one of the balls.
Review of systems. Of the 10 systems that were reviewed, all were negative apart from the recent eye trauma. Past, family, and social history (PFSH) also were obtained.
Visual acuity. 20/200 OD, 20/20 OS.
Exam. Twelve elements of the exam, plus the mental assessment, were performed. The external exam revealed proptosis of the right eye and a small laceration of the upper eyelid, which had been sutured by the ED physician. Anterior segment exam revealed a small blood clot in front of the iris with mild cells in the anterior chamber (AC). It was difficult to view the posterior pole due to the proptosis of the right eye and haze in the AC. In the right eye, the computed tomography (CT) scan revealed bone fractures of the orbital floor, anterior and lateral wall of the right maxillary sinus, and bilateral nasal bone. Also, the optic nerve was being stretched as a result of the proptosis.
Assessment/Plan. Because of cells in AC, intravenous steroids were administered. The stretched optic nerve, as viewed on the CT scan, put the patient at risk for traumatic optic neuritis. Suture placed by ED physician is present. Recheck in office tomorrow morning and plan to remove suture at 1 week during follow-up in office.
CPT code. Code 99284, an ED evaluation and management (E&M) code, was submitted to the patient’s commercial insurance. Place of service is 23.
ICD-10 diagnosis codes. The practice submitted H05.20 Unspecified exophthalmos; H20.041 Secondary noninfectious iridocyclitis, OD; H21.01 Hyphema, OD; S01.111A Laceration without foreign body of right eyelid and periocular area, initial encounter; and S05.11XA Contusion of eyeball and orbital tissues, OD, initial encounter. (Note: Although H21.01 has an Excludes1 note for S05.1-, payers have frequently been ignoring those edits.)
We subsequently saw the patient 4 more times (after 1 day, 5 days, 7 days, and 13 days). Visual acuity at 13 days was 20/20 OD and 20/20 OS.
Justifying the CPT Code
When coding, your documentation must justify the code used. CPT code 99284 requires a detailed history, a detailed examination, and medical decision making of moderate complexity.
For a detailed history, you need to document the following: a chief complaint; a history of present illness (HPI) that is extended (4-8 elements); a review of symptoms (ROS) that is at least extended (2-9 systems reviewed); and a PFSH that is at least pertinent.
For a detailed examination, you must document 9 to 12 elements.
The complexity of medical decision making is determined by the number of diagnosis and management options; the amount and/or complexity of data; and a table of risk that has 3 components (presenting problems, diagnostic procedures ordered, and management options selected).
Note: ED E&M codes don’t distinguish between new and established patients.
Examples provided by Ms. Anderson, who is CFO/Administrator of Black Hills Regional Eye Institute, Rapid City, S.D., and Ms. Delaney and Ms. Brown, who are practice administrator and technician supervisor, respectively, for Esther V. Rettig, MD, PA, in McPherson, Kan. Relevant financial disclosures: None.
For a second case study, see below. For a quick guide to documenting the history, see “Get Your History Right” (June 2015, Practice Perfect).