News from the AOA's Blog

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

Optometrists have been doing procedures for decades that are that are listed in the Surgery section of Current Procedural Terminology© (CPT). Among those services are the removal of foreign bodies from the eye and adnexa, correction of trichiasis, closure of punctum by plug, etc. As is true of all CPT codes, they must be used only when the service matches the definition in CPT, and they must be used according to the rules established by and recorded in CPT.

As is true with each section of CPT, the Surgery section begins with “Surgery Guidelines.” Within the Guidelines section, one can find the “CPT Surgical Package Definition.” It reads, “The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure by procedure basis, a variety of services. In defining the specific services ‘included’ in a given CPT surgical code, the following services are always included (emphasis added) in addition to the operation per se…” 

The section includes six required elements, the second of which is:

• “Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical).”

A strict reading of that bullet point would require that an office visit done on the day before the surgery or on the day of the surgery and related to the surgery be included in the reporting of the surgical code and not reported in addition to the surgery code. A literal interpretation of “Subsequent to the decision for surgery” seems to indicate that if a patient enters the office and the doctor discovers the need for surgery during the visit the visit would be included in the surgery and wouldn’t be billed separately. As is true for many statements within CPT, this one is not as clear as it might be and therefore leaves room for disagreement and often results in a ‘judgment call’ by the doctor and staff and possibly later by the doctor/staff and a payer’s auditor.

Consider this example: A patient reports eye pain during the case history, and the doctor finds a corneal foreign body during the slit lamp examination. After explaining the situation to the patient and recommending that the foreign body be removed immediately, the doctor receives the patient’s consent and removes the foreign body. Following treatment, the patient is reappointed for the next day to permit examination of the healing cornea. The medical record for the day includes a case history, elements of the physical examination, a diagnosis or two, and notes explaining the need for surgery. The record also includes a description of the foreign body and notes stating that the doctor removed the foreign body at the slit lamp. How should this encounter be billed?

Answer: The surgical service should be billed alone, 65222, without a separate office visit, accompanied by the ICD code appropriate to the corneal foreign body. Even though the patient did not complain specifically of a foreign body, the patient’s reason for visit (eye pain) and the subsequent discovery of the reason for the pain (presence of a foreign body) assumes the office visit to be included in the definition of the surgery. The post-operative visit(s) will be reported separately, of course, as the 65222 has a zero-day post-operative period.

Note: Most minor ophthalmic surgical procedures have a zero-day post-operative period, meaning that office visits following the surgery may be billed in addition to the surgery, beginning on the first day post-operation. Code 68761 is an exception, in that it has a 10-day global period, meaning that any visits related to the surgery are included in the surgery “package” and should not be billed separately, until at least 10 days post-operatively.

Consider a second example: The patient enters the office for her regularly scheduled visit for the management of her primary open-angle glaucoma. She reports no eye problems or discomfort, but during the examination the doctor discovers vertical scratches on her cornea that stain with fluorescein. The cause of the scratches is identified as the doctor finds several eye lashes on each lid impinging on the cornea. The doctor completes the visit for management of the patient’s glaucoma, explains the situation, the patient agrees that the lashes should be removed, and the doctor proceeds to remove the lashes at the slit lamp. Should an office visit be billed in addition to the correction of trichiasis, 67820?

Answer:  In such cases, because the reason for the visit was clearly not related to the surgery, the visit would be billed in addition to the surgery, with a 25 modifier on the office visit code, reported with the 67820. The modifier indicates to the payer that the visit was indeed significant and separately identifiable with respect to the surgery and that the documentation will support the appropriateness of billing it in addition to the surgery. The office visit would be reported with the ICD code describing the original reason for the visit: open-angle glaucoma; and the procedure would be reported with its supporting diagnosis, in this example, trichiasis, 374.05.

John Rumpakis, O.D., well-known lecturer on issues related to medical records, coding, etc., provided the following quotations from Medicare’s current manual for the National Correct Coding Initiatives edits relative to global periods, minor surgical services and office visits:

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service.

However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.  If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”

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