Anesthesia Coding Alert

Question: Our anesthesiologist was present during ophthalmic surgery to remove a foreign body that punctured a child’s eye. How would I select the correct ICD-10 option?

Virginia Subscriber

Answer: Delve into the surgeon’s documentation to verify which eye was affected, because this will lead you to the correct diagnosis. 

In ICD-10, you base your choice on the affected eye rather than whether metallic fragments are present, unlike ICD-9 options 871.5 (Penetration of eyeball with magnetic foreign body) and 871.6 (Penetration of eyeball with [nonmagnetic] foreign body). Both 871.5 and 871.6 will expand to: 

• S05.50XA – Penetrating wound with foreign body of unspecified eyeball, initial encounter
• S05.51XA – Penetrating wound with foreign body of right eyeball, initial encounter
• S05.52XA – Penetrating wound with foreign body of left eyeball, initial encounter.