• Coding Top 10: Billing Irrigation for Chemical Injury, Audit Tool Applied to Eye Visit Codes, Complete Review of Systems When Not Pertinent to Exam

    Coding Top 10, December 2020

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    The Academy Coding Experts receive daily questions at coding@aao.org and icd10@aao.org. We are committed to providing accurate responses so that practices are confident in their billing and coding.

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

    1. Billing for Smoking Cessation Counseling
      I was made aware there are two CPT codes for smoking cessation counseling. Are they appropriate for ophthalmologists to use?

    2. Billing Irrigation for Chemical Injury
      Our physician irrigated a patient’s eyes using the Morgan lens device after a chemical injury. Is this separately billable?

    3. Superglue to Eye
      Our patient got superglue in their right eye. Our physician examined the patient and debrided the lashes. What CPT code is billed for the removal of glue from lashes?

    4. Audit Tool Applied to Eye Visit Codes
      Our compliance department is in the process of reviewing our new patient Eye visit codes, and they are down-coding our comprehensive codes to intermediate exams because we are missing the review of systems and past, family and social histories. Do we need to have this documentation?

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

    6. Dilation for E/M Codes
      Our billing department has stated dilation is only necessary for Eye visit codes, but not E/M codes. Is our pediatric ophthalmologist not required to dilate when billing 99214?

    7. Complete Review of Systems When Not Pertinent to Exam
      If a technician or physician is unable to perform a complete review of systems because they are not pertinent to today’s exam, can he receive full credit for stating all others are not pertinent to the patient’s condition?

    8. Do non-covered tests count in MDM
      Is the refraction, Amsler grid, glare testing, etc., considered tests for amount and/or complexity of data to be reviewed an analyzed with the new E/M documentation criteria?

    9. Artificial tears qualify as prescription medication
      Under risk of complications and/or morbidity or mortality of patient, do artificial tears for the dry eye patient count as prescription drug management?

    10. Example of risk factors for minor surgery
      What is an example under risk of complications and/or morbidity or mortality of patient management of minor surgery with identified patient or procedure risk factors?