Home Health ICD-9/ICD-10 Alert

Don't be blinded by case mix points -- documentation is essential for 369.xx codes.

Just because a patient's vision is considered partially or severely impaired on the OASIS doesn't mean he qualifies for blindness and low vision case mix points. Find out when it's appropriate to list a diagnosis code for impaired vision and when doing so could land you in hot water.

Since revised PPS went into effect Jan. 1, there has been a noticeable increase in home health agencies reporting codes in the new Blindness and Low Vision Case Mix category, says Sparkle Sparks, MPT, HCS-D, COS-C, with Redmond, WA-based OASIS Ans-wers. But listing these codes without proper documentation is a mistake, she says.

Codes in the Blindness And Low Vision Case Mix Category include:

• Select codes from the 369.0x (Profound im-pairment, both eyes) subcategory: Including 369.01-369.08;

• All codes in the 369.1x (Moderate or severe impairment, better eye, profound impairment lesser eye) subcategory: 369.10-369.18;

• All codes in the 369.2x (Moderate or severe impairment, both eyes) subcategory: 369.20-369.25;

• 369.3 (Unqualified visual loss, both eyes);

• 369.4 (Legal blindness, as defined in U.S.A.); and

• 950.x (Injury to optic nerve and pathways).

Impaired vision on the OASIS doesn't automatically equal a visual impairment diagnosis. "One coder told me that a consultant had advised that if a patient couldn't turn her head because of an injured neck, then, she could code for her with one of the a visual impairment codes such as 369.3," says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.

There isn't always a link between the OASIS and ICD-9 coding, Sparks says.

The Centers for Medicare & Medicaid Ser-vices has said in its OASIS Q&A that a person who could not turn her head could be marked partial impairment on M0390, but don't make the leap to coding her with a visual impairment diagnosis code, Selman-Holman says.

Notes at the beginning of the ICD-9-CM entry for the 369 (Blindness and low vision) category state "Visual impairment refers to a functional limitation of the eye (e.g., limited visual acuity or visual field). It should be distinguished from visual disability, indicating a limitation of the abilities of the individual (e.g., limited reading skills, vocational skills), and from visual handicap, indicating a limitation of personal and socioeconomic independence (e.g., limited mobility, limited employability)" [italics added].

Bottom line: "When completing M0390 for vision, we're not giving a visual acuity exam; we're looking at how the patient functions in his environment," Sparks says.

Also keep in mind that both the OASIS data item and the blindness and low vision codes assume vision with correction, Selman-Holman says. A patient can be legally blind but see well enough with her glasses to be able to function safely in her home.

Example: Your patient was in a motor vehicle accident. When the airbag deployed, her cheek hit the dashboard, and as a result, her eyes are swollen shut. If she could use her arms to prop her eyes open, she would be able to see fine, but her arms were also broken in the accident. And even if she could prop her eyes open, it wouldn't be practical or functional, Sparks says.

Her problem is that the periorbital swelling has impacted her functional vision, not her visual acuity, Sparks says. The swelling won't allow her to safely negotiate her environment.

In this case, M0390 would likely be scored either "1" (Partially impaired) or "2" (Severely impaired) depending on the severity of her visual limitations. But it would not be appropriate to list a 369.xx code. Even though the instruction for these codes mentions the word "functional," they are describing deficits of the visual pathway (eye, optic nerve, visual center of the brain), not external causes that impact vision, Sparks says.

If you're going to use a 369.xx code, you need documentation from the physician saying your patient has been diagnosed with visual impairment, vision loss or blindness, Sparks says.

When your patient's functional visual deficit is caused by such things as a documented disease, impairment of the optic nerve, a problem with the visual pathway of the eye, or a problem with the part of the brain that guides sight, you have reason to list one of the visual impairment diagnosis codes, Sparks says.

Ask the doc: If you suspect that a patient has a condition, such as a disease of the eye, that is impacting his vision, you need to check with the doctor before listing a diagnosis code, Sparks says.