Exdion Health

A red eye is a routine complaint for most urgent care providers. But beneath the surface, eye infections present a nuanced landscape of diagnoses, treatment options, and, yes, lucrative coding opportunities. Navigating this terrain while ensuring optimal patient care takes a combination of clinical expertise and financial savvy. This blog post equips owners, managers, and practitioners with the knowledge and tools to handle eye infections like seasoned pros, emphasizing maximizing coding accuracy and reimbursement.

Diagnosing with Precision for Optimal Coding:

• History and Symptoms: A detailed patient history sets the stage for accurate coding. Ask about fever, pain, contact lens use, recent injuries, and discharge characteristics. Pus-like discharge points towards bacterial conjunctivitis (ICD-10 code H10.021 left, .022 right, .023 bilat), while watery discharge suggests viral conjunctivitis (B30.9) or allergic conjunctivitis (H10.1 acute or H10.45 chronic)
• Examination: Utilize bright light and magnification to assess redness, swelling, discharge, corneal involvement, and pupil reactivity. Be prepared to differentiate conjunctivitis from styes (H01.0), chalazia (H00.1), and uveitis (H20.0), as each carries its own code.
• Tests: Consider fluorescein staining to identify corneal abrasions (S05) and perform a rapid test for viral conjunctivitis (87809). Documenting these tests strengthens your claim justification.

Procedures at Your Fingertips for Revenue Enhancement:

• Foreign Body Removal: Equip yourself with proper tools and magnification to safely remove superficial corneal foreign bodies (- 65220,65205,65210 & 65435 may need modifier -25). Refer complex cases to an ophthalmologist but remember to bill for your initial assessment and management (99203 or 99204 – new patient).
• Eye Irrigation: Utilize sterile saline solution to flush away debris and soothe irritated eyes. This simple procedure, often combined with the visit, adds to your overall claim value.
• Medication Administration: Administer prescribed eye drops or ointments following proper technique and ensuring patient education. Documentation of medication instructions further strengthens your claim.

Treatment Options:

• Bacterial Conjunctivitis: Prescribe topical antibiotics. Advise patients on hand hygiene and avoidance of contact lenses, minimizing potential future visits.
• Viral Conjunctivitis: Supportive care with cold compresses, artificial tears, and pain relief typically resolves within 7-10 days. Documenting patient education ensures appropriate follow-up and prevents unnecessary re-visits.
• Allergic Conjunctivitis: Recommend antihistamine eye drops and avoidance of triggers.
• Sties and Chalazia: Warm compresses and lid hygiene practices are advised. Refer persistent cases for incision and drainage and bill for your preoperative consult.

Knowing When to Refer and Maximize Revenue:

• Vision loss or significant blurring: Referrals to an ophthalmologist are crucial in these cases. Documenting the urgency and rationale for referral strengthens your claim.
• Severe pain or corneal injury: Timely referrals and accurate documentation protect your practice from potential liability while ensuring necessary specialist intervention.
• Uveitis or orbital involvement: Prompt referrals and detailed medical records ensure optimal patient care and justify higher complexity levels in your coding (e.g., 99214).
• Presumed fungal or parasitic infection: Referrals and comprehensive documentation are essential for these atypical cases, potentially leading to additional diagnostic testing and revenue opportunities.
• Failure to improve with initial treatment: Documenting treatment progress and rationale for referral ensures continuity of care and avoids potential denials for re-visits related to the same condition.

Billing Accurately for Optimal Reimbursement (E&M Versus Eye Visit Codes):

E&M Codes:

• 99203(Level 3 New patient visit): Appropriate for new patients with low level of complexity of medical decision making, requiring a medically appropriate history and/or examination. (Or) when using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 99204(Level 4 New patient visit): Suitable for new patients with moderate level of complexity of medical decision making, requiring a medically appropriate history and/or examination. (Or) when using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
• 99213: (Level 3 established patient visit): Appropriate for established patient with low level of complexity of medical decision making, requiring a medically appropriate history and/or examination. (Or) when using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
• 99214: (Level 4 established patient visit): Appropriate for established patient with moderate level of complexity of medical decision making, requiring a medically appropriate history and/or examination. (Or) when using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• Eye visit codes:(Elements based with the treatment plan for eye)
• 92002: (Appropriate for New patient) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate
• 92004: (Appropriate for New patient) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits.
• 92012: (Appropriate for Established patient) Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
• 92014: (Appropriate for Established patient) Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
• Modifier 25: For significant or prolonged services in addition to the E&M code.
• Billing Eye visit code during below situations lead to denial and/or Patient responsibility:
  • ICD 10 code is not a covered diagnosis.
  • POS is not Office.
  • Frequency of Eye visit codes were exceeded/Year/Payer.
  • E/M required for medical diagnosis.
  • Subject to down coding based on diagnosis.
  • Commercial plan still recognized consult codes. (Medicare will not recognize consult codes from 2010)
  • Telemedicine
  • Prolonged services.
  • Payer allowable.
• Correct diagnosis codes: Be specific to the type of infection (bacterial, viral, etc.) and laterality (left, right, or both).

Partner with ExdionHealth for Seamless AI Coding and Revenue Enhancement:

Don’t let complex coding and missed revenue opportunities cloud your focus on patient care. ExdionHealth’s intelligent AI platform, ExdionACE, seamlessly integrates with your workflow, automating medical coding with industry-leading accuracy. Our rule-based and machine learning technology ensures precise capture of every billable service, maximizing your reimbursement while minimizing denials. ExdionACE goes beyond, offering comprehensive CDI support, proactive revenue leakage identification, and actionable insights to optimize your practice efficiency. Partner with ExdionHealth and let us clear the way for financial sustainability and focus on what you do best – providing exceptional care to your patients.