APR 20, 2021
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
|Amount and/or complexity of data
||Independent historian – Mom
|Risk of complications
||Major surgery without identified patient or procedure risk factors
E/M code 99203 -57/99213 -57
- 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.
- 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.