• Corneal Laceration - Coding for Ocular Trauma case study


    First day on the job at a home improvement store, 18-year-old Blake cut the metal band around layers of stacked wood. The metal band flipped lacerating his cheek to forehead, including eye on the left side of his face. Blake was driven to closest hospital emergency department by manager.

    The emergency department physician closed the skin laceration, packed the left eye with antibiotic ointment and applied a pressure patch. Unknown if ophthalmology consult was requested. Instructed patient to see an ophthalmologist, “First thing in the morning for severe corneal abrasion”.

    Blake and his Mom are at the office door when staff arrives. Blake is in terrible pain and nauseated.


    Action of Staff:

    • Technician takes Blake to exam room and asks permission for Mom to accompany him per HIPAA requirements.
    • Tech obtains name of employer and manager and gives info to front staff to call for injury report. This is a workers’ compensation claim.
    • Front office notifies scheduled patients of emergency and offers to reschedule if patient is unable to wait.

    Medical Decision Making for E/M coding

    Number and/or complexity of problems 1 acute injury that poses a threat to bodily function High
    Amount and/or complexity of data Independent historian – Mom Low
    Risk of complications Decision regarding emergency major surgery High

    E/M code 99205 -57/99215 -57

    • Plus, 99058 Emergency disrupting office hours

    Surgery

    • 65280 Repair of laceration; cornea, and/or sclera, perforating, not involving uveal tissue which has a 90-day global period.
    • Modifier -57 indicating the office visit was performed to determine the need for surgery is appended to 99205/99215.

    ICD-10 Selection

    • S05.32XA Corneal laceration without prolapse or loss of intraocular tissue, left eye
    • W22.8XXA Striking against or struck by other objects, initial encounter

    Postop Care

    • During postop period Blake is fit for a bandage contact lens.
    • Claim submission included 92071 Fitting of bandage lens and V2599 Supply of bandage lens

    The Rest of the Story
    Following healing of the laceration, Blake was referred to a cornea specialist as corneal transplant would eventually be needed. Corneal scar diagnosis (H17.12) plus S05.32XS Corneal laceration without prolapse or loss of intraocular tissue, left eye, indicating sequela may be required for workers compensation.