Corneal Foreign Body Visits
Coding foreign body removal by an eye specialists is our focus in this article. The following would be used for removal of foreign body in cornea:
ICD 10 Codes
T15.00XA - Foreign body in cornea, unspecified eye, initial encounter
T15.00XD - Foreign body in cornea, unspecified eye, subsequent encounter
T15.00XS - Foreign body in cornea, unspecified eye, sequala
T15.01XA - Foreign body in cornea, right eye, initial encounter
T15.01XD - Foreign body in cornea, right eye, subsequent encounter
T15.01XS - Foreign body in cornea, right eye, sequela
T15.02XA - Foreign body in cornea, left eye, initial encounter
T15.02XD - Foreign body in cornea, left eye, subsequent encounter
T15.02.XS - Foreign body in cornea, left eye, sequela
The “unspecified eye” codes should never be used. You are an eye specialist. You are supposed to know which eye contains the corneal foreign body. With that in mind, the choice becomes either right eye or left eye. The case we are considering is the left eye.
Looking at the chart above, the appropriate diagnosis code for the case we are considering is T15.02XA. The 2 in this code tells us it is the left eye (it would be a 1 for right eye). The A in the code tells us it is an initial encounter (the other options are D-subsequent and S-sequela). The ICD-10 diagnosis code T15.02XA is foreign body in the cornea, left eye, initial encounter. The procedure code that we would use for this procedure would be 65222 - removal of foreign body, external eye; corneal, with slit lamp.
CPT 65222 is a bundled code. That means if you have two or more foreign bodies in the same tissue with the same eye, on the same day, you can only bill once for the multiple foreign bodies. But, if you have both a corneal foreign body and a conjunctival foreign body in the same eye at the same time, then you can bill for both. In the case of both a corneal and conjunctival foreign body in the same eye at the same time, you would use the CPT codes 65222 and 65205 using the appropriate diagnosis code with each procedure code.
It is important to note that CPT code 65222 is a per eye code, so the other case to consider is if you have a corneal foreign body in the right eye and the left eye at the same time. In this case, you can bill for the corneal foreign body removal in each eye using the RT and LT modifiers with the procedure code. The multiple surgery rule would apply, so you would use the 52 modifier on the second eye.
Documentation suggestions
Make sure your documentation identifies how many corneal foreign bodies exist, the exact location with a note of the specific tissue involved (e.g. corneal or conjunctival) as well as the depth of each foreign body.
Instead of using a SOAP notes (i.e. Subjective, Objective, Assessment, Plan) approach for documentation, it is best to use a surgical notes approach. The surgical notes approach contains the following elements:
Describe the medical condition
Describe previous treatment attempted
Document informed consent
Describe the procedure
Outcome statement
Discharge instructions
Can I bill and exam code in addition to foreign body removal?
The answer is yes and no.
The answer is no if during your examination of the patient you discover the corneal foreign body, it is the only problem you discover, and you remove it the same day. “The initial evaluation for minor surgical procedures…is always included in the global surgery package".” (Medicare Claims Processing Manual, Chapter 12, Section 40.1.B)
The answer is yes if you discover another problem that is unrelated to the minor surgical procedure that needs to be addressed during the same office visit. For example, if you identify a blepharitis and a corneal foreign body, then you would code for the corneal foreign body removal with the diagnosis of corneal foreign body and also code 99202-99215 with modifier 25 with the diagnosis of blepharitis. The 25 modifier is a significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service.
In the case where you are billing an exam code with the surgical code, the E&M documentation must “stand alone” from the surgical procedure and be unrelated to the surgical procedure. To be clear to anyone auditing your records, separate your E&M documentation from the surgical procedure documentation. Make sure your electronic medical recored is able to do this.