Fluorescein dye and a Wood lamp were used to rule out a corneal abrasion. What Current Procedural Terminology (CPT®) code should be used to report this?

The examination and fluorescein dye test are included in the evaluation and management (E/M) service and are not reported separately. However, the eye examination and history performed and documented may support a higher level E/M code. The 1997 E/M Documentation Guidelines include the reporting criteria for a single system specialty examination (eg, eye). These guidelines may be found at www.cms.hhs.gov. International Classification of Diseases, Ninth Revision, Clinical Modification code 918.1 should be reported if there is a corneal abrasion; code 930.0 is used to report a corneal foreign body. If there were no findings on examination, the symptoms should be reported. For example, report eye pain with code 379.91 or redness or discharge of eye with code 379.93.

Which code is used...

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