A very common scenario in many optometric practices is, a patient presents with right eye discomfort, and the notes indicate the patient has something in their eye. The patient often does not know what it is, where it came from, or where it is located, but they know they want it out. Surely you will be compensated for the work required to evaluate the situation, right?
Unfortunately, no. All minor surgical procedures, of which foreign body removal is one, are deemed to include the office visit unless one condition is true: the office visit was for a completely unrelated reason. As an example, the patient presents for a regularly-scheduled glaucoma evaluation and you happened to find the foreign body through the course of your normal evaluation.
In instances where the visit and minor surgical procedure are unrelated, both can be coded. The office visit would carry a -25 modifier to indicate that it was for an unrelated reason and each CPT code would be linked to a distinct ICD-10 code. The claim for our hypothetical situation could look like this (keeping in mind, of course, that the requirements of 99213 would need to be met to use that code). See Example Note: In instances where the visit was related to the foreign body, code only the minor surgical procedure.
