Coding for ocular trauma is something with which ophthalmic practices should be familiar.
Curling iron burn, chemical splashed or super glue in the eye, fireworks, foreign body, lacerations, blunt trauma, car accidents, abrasions by fingernails, tree branches and work-related eye injuries are almost a daily occurrence in ophthalmology.
Case Studies in Ocular Trauma Coding
Commotio Retina Involving Macula
To prepare, best practices have the following emergency steps in place:
- Telephone triage (PDF) available for all who answer the phone. Including the answering service.
- Reserved time slots in daily schedule
- Preauthorization checklist (PDF)
- Especially important for afterhours emergency
- If surgical correction is performed in office, confirm office base surgery is payable.
- Medical equipment available
- Staff policy/training to handle emergencies.
- Who is the payer?
- Patient’s personal insurance
- Work related injury
- The No. 1 reason for delay in payment is failure for employer/employee/patient to file an incident report.
- Auto insurance*
- Homeowner insurance*
- Stay calm. Especially when others around you are not.
Consider These Additional Codes for Commercial Payers:
First published in 1993, designed initially to accommodate workers compensation emergency visits, the following family of codes may be submitted in addition to the appropriate level of evaluation and management (E/M) or eye visit code.
- 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 PM and 8:00 AM
- 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
- Do not submit any of the above codes to Medicare Part B or Medicaid. They are already factored into the payment of the exam.
- Commercial plan coverage of this family of code varies.
- Example 99050 is payable by some commercial plans.
- Commercial plans may provide additional compensation to physicians for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic services.
- Payment may not cover other codes in the family.
- Either the commercial plan will have an allowable, indicate patient responsibility, or state payment is included in the exam per CMS policy.
- The eye visit codes may be reserved for vision exams, depending on the commercial payer. Consider reporting the appropriate level of E/M. E/M should also be considered when the physician face-to-face time is a factor.
Tips for ICD-10 Code Selection
- Accident codes, i.e., encounters with whales, are not always required for payment. In fact, the commercial payer seeing this additional information, may try to pass financial obligation to homeowners insurance, etc. These unique ICD-10 codes may be required for workers compensation.
- Sequela ICD-10 codes which end in an S, are not always recognized by nonworkers compensation payers. Better to report diagnoses with an A or a D in the last position.
Article - Ocular Trauma and Guns: The Need for Data (EyeNet® Magazine, March 2021)