Get trusted answers to your coding questions from the Academy’s coding experts, so you can bill and code with confidence. The November coding selections include:

1. Billing Cataract Surgery in Conjunction With iStent Inject
   When our surgeon performs cataract surgery plus iStent inject on a Medicare Part B patient, how should the surgeon and the facility submit the claim?

2. Operative Report Storage
   Our surgical operative reports are kept in the electronic health record (EHR) system of the facility, not our practice. We have access to this EHR as we are under the same taxpayer identification number (TIN). Do we have to have a copy of the operative report in our patient chart for the practice in case we are audited?

3. Terminated Ptsosis Repair Billing
   Our surgeon was performing ptosis surgery of the right eye, when the eyelid tissue proved to be too thin and fragile. The tissue superficial to the Wright needle and fascia tore, leaving the needle/fascia complex exposed. It was decided that proceeding further with the ptosis surgery was not possible under these circumstances. Instead, the torn eyelid tissue laceration was repaired with multiple deep 6-0 plain gut sutures and superficial 6-0 vicryl sutures.

   Should we bill for both 67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material and 67930 Suture of recent wound, eyelid, involving lid margin, tarsus and/or palpebral conjunctiva direct closure; partial thickness?

4. Established Patient ROS Documentation
   Is there a specific amount of review of systems (ROS) we should be documenting for established patients?

5. Billing DWEK
   My surgeon states she performed DWEK. I am unsure what CPT code we should be using.

6. Corneal Culture in Facility
   Our surgeon performed CPT code 65430 Scraping of cornea, diagnostic, for smear and/or culture in the ASC. I do not have a facility fee amount for this service. Are we allowed to bill for this in a facility?

7. Billing AC Tap in Post-operative Period
   Are anterior chamber taps, billable in the post-operative period?

8. Oil Removal Diagnosis When Detachment Is No Longer Present
   What is the proper diagnosis code for removal of oil months after the retinal detachment has been repaired and the patient no longer has the detachment?

9. Payer Denial of Exam Same Day as Minor Surgery
   Our commercial payer denied our exam submitted the same day as an excision of lid lesion. They stated it was incidental to the primary procedure. Below is how we submitted. Should we rebill or appeal?
   Diagnosis D23.121 Benign eyelid lesion
   CPT: 92014 - 25
            67840 - 59 - E1

10. Dry Eye Diagnosis for Epilation
    Our physician performed epilation with a primary diagnosis of dry eyes; however, we have not seen this diagnosis attached to this procedure before. Is this payable?