New E/M Rules for Office Visits, Part 4: Cornea and Oculofacial Exams

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Do you submit Evaluation and Management (E/M) codes 99202-99215? For patient encounters that take place in 2021, documentation of the history and exam just needs to reflect what is medically relevant to the physician and is not part of the chart note audited by the payers. In August and September, EyeNet discussed the medically relevant history; in October, EyeNet gave examples of anterior segment and pediatric exams; this month, Carrie A. Lembach, DO, focuses on the cornea exam, and I’ll provide examples of oculofacial exams.

Cornea Examples

Abrasion. After confirming the presence of a corneal abrasion, you might fit (CPT code 92071) a bandage contact lens (92236 or V2599), which would be dispensed as an out-of-pocket cost to the patient. Under the new E/M rules, Dr. Lembach would make sure that the chart documents evaluation of the patient’s visual acuity (VA) and examination of the conjunctiva, ocular adnexa, pupils and iris, cornea, anterior chamber, and lens.

Foreign body. What about removal of a superficial corneal foreign body at the slit lamp (CPT code 65222)? Dr. Lembach said that the exam elements that she listed for the corneal abrasion example would also be needed when performing an E/M exam in this case. Since CPT code 65222 has a zero-day global period, new exams are billable, but exams for returning patients must meet the definition of modifier –25 to be paid. Even though the established patient exam is medically necessary, it is not separately billable if it is per­formed solely to confirm the need for the foreign body removal.

Dr. Lembach is a cornea specialist at Arena Eye Surgeons in Columbus, Ohio.

Oculofacial Examples

Blepharoplasty. Before COVID-19, I accompanied my sister-in-law Jill (not her real name) to an oculofacial special­ist’s practice to address her complaints of bilateral heavy, excessive upper lid skin. This was pushing the eyelashes nearly into her eyes, with the left lid worse than the right. Two weeks earlier, she had undergone a comprehensive exam by her general ophthalmologist. The visit with the specialist took less than 20 minutes. After documenting a functional complaint, the surgeon felt that it was medically necessary to perform a VA exam and an ocular adnexa exam via the slit lamp. Next, the surgeon turned the exam chair 90 degrees and performed a tangent screen visual field followed by external ocular photography. Both of these tests are required by Jill’s commercial payer. Risk and benefits were discussed, and Jill was keen to proceed with surgery. For a list of each Medicare Administrative Contractor’s unique requirements for establishing the need for blepharoplasty surgery, visit aao.org/lcds.

Lid lesions. According to payer re­quirements, what elements of the exam are deemed medically relevant prior to lesion removal? You should assess and document VA; the location of the lesion(s); the lesion(s) size (in cm); whether or not a lesion interferes with vision, obstructs an orifice, or restricts eyelid function; and whether or not a lesion causes misdirection of eyelashes or the eyelid, restricts lacrimal puncta, interferes with tear flow, or touches the globe. Also document any removal of molluscum contagiosum; the method of removal, such as shaving, surgical excision, or destruction; and the depth of excision. This last detail will help you determine whether to select a CPT code from the Integumentary section or the Eye and Ocular Adnexa section of the CPT code set. You can take external photographs to confirm that the lesion removal is not the cosmetic removal of skin tags. For medically necessary removal of up to 15 lid lesions, use CPT code 11200 Removal of skin tags, multi­ple fibrocutaneous tags, any area.

Further Reading

New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History (August 2020, EyeNet)
Taking the history. Doctors share examples for cataract, cornea, glaucoma, and pediatric ophthalmology.

New E/M Rules for Office Visits, Part 2: How to Document the Retina Exam (September 2020, EyeNet)
Taking retina histories. Plus the nonoffice exam.

New E/M Rules for Office Visits, Part 3: The Medically Relevant Exam (October 2020, EyeNet)
Anterior segment and pediatric examples.