Ocular surgery due to trauma is frequently within the purview of the retina surgeon. When one is coding for removal of an intraocular foreign body (IOFB), it is necessary to be aware of the following: differentiation between a magnetic and nonmagnetic foreign body; proper diagnosis codes, which have been changed in ICD-10-CM; surgical Current Procedural Terminology (CPT) codes; and National Correct Coding Initiative (NCCI) bundles. These points are discussed below.
DIFFERENTIATING BETWEEN IMPLANTS, FOREIGN BODIES, AND FOREIGN BODY TYPES
Before one can differentiate between a magnetic and nonmagnetic foreign body, one must be sure that the object in question is indeed a foreign body and not an implant.
For coding purposes, objects that are synthetic or natural in origin (wood, glass, metal, etc.) are considered foreign bodies. A foreign body is an object, or more than one object, that has entered and is present in the body but does not belong there and was not placed there by a surgeon.1
In retinal trauma, the sites where IOFBs are most frequently encountered are in the anterior and posterior segments and embedded in lacerations; however, foreign bodies can also be encountered in the conjunctiva and the orbit. These objects ended up in the body as a result of some type of trauma, such as an accident, natural force (wind blowing something in the eye), or other similar method of delivery.
Below is a list of CPT codes commonly used in retinal trauma cases that address the removal of foreign bodies.
65235 Removal of foreign body, intraocular; from anterior chamber of eye or lens
65260 Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior route
65265 Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction
Trauma cases often also necessitate the use of one of the laceration repair codes below.
65280 Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue
65285 Repair of laceration; cornea and/or sclera, perforating with reposition or resection of uveal tissue
65286 Repair of laceration; application of tissue glue; wounds of cornea and/or sclera
In contrast to a foreign body, an implant is a manufactured object that has been placed in the body by a surgeon as part of a surgical procedure. When complications related to the placement of an implant arise, its removal or repositioning is often performed. Sometimes is it left alone.
Do not code the removal of an implant as removal of a foreign body. An intraocular lens (IOL) is never considered a foreign body and should never be listed as such in an operative note. It is an implant. When one has become dislocated, it should be referred to as a dislocated IOL or dislocated IOL implant. Further detail should note the place of dislocation (anterior chamber, posterior chamber, posterior vitreous, lying on the retina, etc.)
Examples of specific CPT codes addressing removal of implanted material that are commonly used in retina cases include the following:
65920 Removal of implanted material, anterior segment of eye
67120 Removal of implanted material, posterior segment, extraocular
67121 Removal of implanted material, posterior segment, intraocular
Coding for Magnetic vs. Nonmagnetic Foreign Bodies
ICD-10-CM Coding. For trauma cases there are special rules for diagnosis coding.2,3 Diagnosis codes generally used in these types of cases can be found in Chapter 19 (Injury, Poisoning and Certain Consequences of External Causes) of ICD-10-CM.4 Diagnosis codes for more specific causes may be found in Chapter 20 (External Causes of Morbidity), but use of these additional codes is not mandatory.4
Instructions prefacing Chapter 19 explain that most diagnosis codes in the chapter have 7th character values, and that the 7th character A requires mastering, given the descriptor “initial encounter,” which is a misleading name. In fact, the A is to be used by all providers who see a patient if they are providing active treatment. It does not matter whether it is the initial physician who examined the patient or the surgeon who subsequently operates on that patient. The 7th character A is used while the patient is receiving treatment for the condition, including surgical treatments, emergency department encounters and evaluation, and continuing treatment by the same or different physicians.
For IOFBs, the most commonly used codes include S05.51 (Penetrating wound with foreign body of right eyeball) and S05.52 (Penetrating wound with foreign body of left eyeball). However, when this family of codes is used, the 7th character is required, and it must be in the 7th position. For example, an IOFB in the right eye would be S05.51xA, where the x is used as a placeholder to ensure that the A is in the 7th position.
In the event that the foreign body is old and has been retained for some time, the appropriate ICD-10-CM codes are found in Chapter 7 (Diseases of the Eye and Adnexa). The main categories are H44.6 Retained (old) IOFB, magnetic, which has the additional instruction, “Use additional code to identify magnetic foreign body (Z18.11).” The Chapter 7 codes are more anatomically specific than those in Chapter 19. For example: H44.652 Retained (old) magnetic foreign body in vitreous body, left eye.
If the foreign body in the left eye is nonmagnetic, the correct code is H44.7 Retained (old) IOFB, nonmagnetic, which includes the instruction “Use additional code to identify nonmagnetic foreign body (Z18.0 – Z18.10, Z18.12, Z18.2 – Z18.2-Z19.9).” A comparable diagnosis for an old retained foreign body in the left eye that is nonmagnetic is H44.752.
The treatment is considered active whether or not the foreign body is magnetic and whether or not it is an old foreign body. There are six characters in each code after laterality is accounted for, so the A can be added without a place marker, for example H44.652A or H44.752A. Because the treatment is active, the A is the proper choice for the 7th character.
Lastly, it is mandatory to use the Z codes, which define the type of material the foreign body is composed of
(eg, glass, metal, wood, stone, or even an unspecified material). It is important to remember to use the Z diagnosis, lest the claim be denied.
Surgical Code Selection. Whereas the diagnosis code selection is determined by whether or not the foreign body is magnetic, the surgical code selection is determined by the method of extraction, as described earlier. The CPT code selection is guided by how the procedure was performed, and it does not matter if the foreign body was magnetic. If a magnet was used, then it is a magnetic extraction; otherwise it is a nonmagnetic extraction—even if the foreign body itself is magnetic.
Case No. 1
History: The patient sustained severe ocular trauma to his right eye while working on machinery, resulting in a corneal laceration with a metallic foreign body. Inspection of the sclera revealed multiple posterior rupture sites. There was a corneoscleral limbal entry site where a large metallic foreign body was situated. The corneoscleral laceration was vertically oriented to the cornea and turned somewhat supranasally on the sclera, extending approximately 2 mm on the sclera and 2 mm to 3 mm on the cornea. Additionally the anterior capsule had been compromised, leading the surgeon to decide to perform a pars plana lensectomy.
Surgery: Surgery consisted of an attempted removal of the metallic foreign body with an 18-gauge magnet. The IOFB ultimately had to be removed using large retina forceps. Further surgery involved primary open globe repair, pars plana vitrectomy (PPV), pars plana lensectomy, and anterior chamber washout. Cultures were taken and intravitreal antibiotics injected.
1. S05.51xA Penetrating wound with foreign body, right eye
2. H26.101 Traumatic cataract, right eye
3. S05.31xA Ocular laceration without prolapse or loss of intraocular tissue, right eye
4. W31.1xxA Contact with metalworking machines
• CPT code 67036 (Pars plana vitrectomy) is bundled in the NCCI with CPT code 65265 and therefore is not listed.
• Magnetic and nonmagnetic foreign body removal codes are bundled; therefore, the code that represented the final method of extraction was selected.
• Because enough information is present on how the metallic foreign body and laceration occurred, the external cause can be coded. Chapter 20 of ICD-10-CM contains the external codes, and the practice felt it might be desirable to use them in this case. Keep in mind, however, that use of these codes is not mandatory for Medicare.
Case No. 2
History: The patient had been involved in a multiple-vehicle accident and sustained a ruptured globe, vitreous hemorrhage, anterior chamber hyphema, and IOFB involving the left eye. Surgery consisted of removal of a metallic foreign body using an intraocular magnet; PPV with removal of vitreous hemorrhage and repair of retinal tear with focal endolaser; and repair of scleral laceration (no uveal prolapse).
1. H33.302 Unspecified retinal break, left eye
2. H43.12 Vitreous hemorrhage, left eye
3. S05.52xA Penetrating wound with foreign body of left eyeball
4. S05.32xA Ocular laceration without prolapse or loss of intraocular tissue, left eye
• Note that the CPT code for magnetic method of removal was selected, even though the ICD-10-CM diagnosis does not specify magnetic or nonmagnetic.
Case No. 3
This journal case presentation revealed that a 57-year-old man had sustained an injury to the right side of his body (right eye and right hand) as well as an injury in the left eye caused by a metallic foreign body when an old bomb from World War II exploded.5 Numerous facial injuries occurred at that time as well as the injury to his left eye. The right eye had minimal visual acuity, a large corneal scar, and was atrophic. Examination of the left eye showed no pathologic conditions externally or on slit-lamp examination; however, ophthalmoscopy revealed an IOFB lying free in the vitreous inferiorly and temporally near the optic nerve head. There was a retina rupture at 7 o’clock. Diagnostic testing with optical coherence tomography and ultrasound showed the IOFB in the vitreous and an atrophic macular area as well as decreased peripapillary retinal fiber layer thickness. Previous eye examinations over the years did not mention the presence of the IOFB. Surgery was scheduled and performed on the left eye and consisted of nonmagnetic removal of the IOFB (1.8 mm in length); PPV with focal endolaser of the retinal break; and phacoemulsification of the cataract with insertion of an intraocular lens.
1. H44.652 Retained (old) intraocular foreign body, magnetic, left eye
2. Z18.11 Retained magnetic metal fragments
3. H33.302 Unspecified retinal break, left eye
4. H25.12 Age-related nuclear cataract, left eye
• Note that this is an example of a retained (old) IOFB and uses a different set of diagnosis codes.
• This is also an example of a magnetic IOFB removed via nonmagnetic surgery.
1. Asbell RL. Surgical coding errors and English 101. Ocular Surgery News. Published in two parts, September 10, 2010, and October 10, 2010.
2. Asbell RL. Troubleshooting the 7th character. Retina Today. 2016;11(2):22-24.
3. Asbell RL. A potpourri of complicated surgical coding cases. Retina Today. 2016;11(5):26-30.
4. CPT 2017 Professional Edition. Chicago, IL: American Medical Association; 2017.
5. Adži´c-Zeˇcevi´c A, Files-Bradari´c E, Petrovi´c M. Overlooked retained intraocular foreign body. Vojnosanitetski pregled. 2015;72(5):463-465. (www.doiserbia.nb.rs/img/doi/0042-8450/2015/0042-84501505463A.pdf)
Riva Lee Asbell
• principal, Riva Lee Asbell Associates, in Fort Lauderdale, Fla.
• financial interest: none acknowledged
CPT codes Copyright 2016 American Medical Association. ICD-10-CM codes © 2016 Optum360, LLC. All rights reserved.