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  • Canalicular Laceration - Coding for Ocular Trauma case study

    At 1pm 11-year-old Ronnie was mowing the lawn when something “flipped up and hit him in the right eye and the eye is bleeding”. Patient’s mother called the office at 4:45pm. Exam revealed right lower canalicular laceration from wire hidden in lawn. History included asking, “When was the last time you had anything to eat or drink?” Ronnie’s answer: “Nothing since breakfast as it was his birthday and the family was going out to an early dinner to celebrate”.
    Note: if exam had taken place in the emergency department the E/M 1997 documentation requirements would apply.

    Action of Staff:

    • ASC notified to add a case that night.
    • Called insurance company for authorization of three possible surgical code options plus staff confirmed actual CPT code with insurance company first thing the next morning.

    Medical Decision Making for E/M coding

    Number and/or complexity of problems 1 acute, uncomplicated injury Low
    Amount and/or complexity of data Independent historian – Mom Low
    Risk of complications Major surgery without identified patient or procedure risk factors Medium

    E/M code 99203 -57/99213 -57

    Surgical Options

    • 68700 -RT Plastic repair of canaliculi, or
    • 68745 -RT Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube, or
    • 68750 -RT with insertion of tube or stent

    Not all commercial plans recognize HCPCS E4 Lower right lid modifier. Modifier -RT is recognized by all payers.
    As all procedures have a 90-day global period, modifier -57 indicating the exam to determine the need for the major surgery should be appended to 99203/99213.

    ICD-10 Selection

    • S01.111A Laceration without foreign body of right eyelid and periocular area

    The Rest of the Story
    Within the global period, the tube was removed in office. This is a part of postop care. If tube was removed outside the 90-day global or if removed by a different physician, it’s part of the E/M or Eye visit code submitted that day.