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Corneal Abrasion

Bernadette Posted Tue 29th of October, 2013 16:15:03 PM

Hello,

We are a primary care pediatric physician's office and we had a patient come in for a swollen eye. Patient complained of slight burning of her eye. Patient wears glasses, not contacts, and did not have a known injury to the eye. The doctor noted no foreign body upon exam, but did a florscein and saw a tiny abrasion on the cornea.Still, no foreign body was present. Would we still be able to bill a corneal abrasion CPT code 65205 even if there was no foregin body present but pt did have a tiny abrasion? We appreciate your thoughts on this ...

SuperCoder Answered Tue 29th of October, 2013 17:43:01 PM

CPT has no specific code for dipping a strip into the eye, so none of the codes in CPT's ophthalmology section will be able to help you.

You should instead include the fluorescein stain in the E/M service (such as 99201-99215, Office or other outpatient visit).

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