Emergency calls frequently occur on Friday afternoons and Mondays. After staff has triaged the calls to determine what is emergent and what is not, you’ll likely find that your schedule is now a bit heavier. To help guide you through the claims process, here’s how to appropriately submit for three common emergency scenarios.
Scenario 1: Foreign Body Removal
A new patient presents with a complaint of foreign-body sensation in the left eye after working on his car. He reports significant pain and is also photophobic. You perform a comprehensive history and an expanded, problem-focused exam. This determines that a piece of metal is embedded in his conjunctiva. You remove the foreign body and ask the patient to return in three days.
Diagnosis: T15.12XA Foreign body in conjunctival sac, left eye, initial encounter
Based on the history, exam elements and medical decision-making, the exam code options are E&M 99202 or Eye visit code 92002. Although Medicare Part B does not require adding modifier -25 to new patient exams, commercial payers might require it.
CPT code: 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service
- You may also submit this code to all payers except Medicare Part B. The payer may either pay the allowed amount or state that it’s a noncovered service and the patient is responsible for the fee.
CPT code: 65210 -LT Removal of foreign body, conjunctival embedded
- Payment should be 100 percent of the exam and the foreign body removal.
Scenario 2: Eyelid Swelling
During the past week, an established patient with chronic bilateral upper- and lower-lid blepharitis and chronic chalazia has experienced increased swelling and tenderness in the left lower eyelid. After increased discomfort, the patient comes in. You perform a problem-expanded history and problem-focused exam. As a result, you diagnose a chalazion in the left lower lid. You decide to excise the chalazion in the office the same day. Due to the patient’s history, you also perform an intralesional injection to prevent recurrence.
Diagnosis: H00.15 Chalazion left lower eyelid
CPT codes: 67800 -LT Excision of chalazion, single; 11900 Injection, intralesional; up to and including seven lesions and JXXXX, depending on the drug used
- Is the exam billable? No. Because CPT code 67800 has a global period of 10 days, the exam must meet the definition of modifier -25, which states it must be separately identifiable from the minor surgery performed on the same day. Although medically necessary, you performed the established-patient exam solely to determine the need to excise the chalazion. Therefore you can’t separately bill for the exam.
Scenario 3: Postop Endophthalmitis
An established patient living in a rural area, 10 days postop from cataract surgery in the right eye, comes in with the complaint of severe pain and loss of vision in that eye. You perform an expanded history and detailed exam and determine that the patient has purulent endophthalmitis. You perform a paracentesis, vitreous tap and an intraocular antibiotic injection.
Diagnosis: H44.001 Unspecified purulent endophthalmitis
CPT codes: 67015 -78 -RT Vitreous tap; 65800 -78 -RT Paracentesis; 67028 -78 -RT Antibiotic injection and JXXXX, depending on drug(s) used
- The vitreous tap has the highest allowable and is not bundled with the paracentesis. It is, however, bundled with the injection. The paracentesis is bundled with the injection as well. Because the paracentesis has the higher allowable, you should not bill the injection; the facility will. The postoperative period does not restart, as modifier -78 indicates that the surgical procedures were related to the cataract surgery. Payment is 80 percent of the allowable for the vitreous tap, 50 percent of the 80 percent for the paracentesis.
- The condition is related to the surgery, therefore, no exam is separately billable; this is considered a postoperative visit.
Note: Commercial payers may not follow the same bundling edits. If the payer allows payment of the injection the same day as a paracentesis, submit 67028 -78 -RT as well.
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About the authors: Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series. Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She oversees the Academy’s Chart Auditing Service and is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series.