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Watch Out for This Vision Coding Trap

Published on Fri Jan 20, 2012

Don't be blinded by available case mix points.

You can earn valuable case mix points when providing care to a patient with a blindness or low vision diagnosis. But beware of upcoding -- just because your patient's OASIS assessment indicates a vision deficit doesn't mean you have a lock on the additional reimbursement.

Look Over M1200

OASIS item M1200 -- Vision with corrective lenses if the patient usually wears them provides a clue that you may need to list a code from the 369.xx (Blindness and low vision) category. M1200 asks the clinician to assess your patient's vision to determine whether it's normal, partially impaired, or severely impaired, says Sparkle Sparks, MPT, HCS-D, COS-C, with Redmond, WA-based OASIS Answers.

"The item's intent is actually to identify the patient's ability to see and visually manage (function) within his or her environment, wearing corrective lenses if they are usually worn," Sparks says.

However, just because the patient has a visual deficit identified on the OASIS doesn't necessarily mean you should list a 369.xx code in M1020/M1022, Sparks says.

"The classification for diseases of the eye is very detailed, and understanding the terminology used is critical. Terms that seem similar may have entirely different meanings. The coder should be sure to fully understand the diagnostic statement in the medical record before assigning a code," says Faye Brown in the ICD-9-CM Coding Handbook with Answers 2010.

As a result, coders may confuse OASIS answers with diagnoses and try to select a 369.xx code to gain case mix points, Sparks says.

Bottom line: The medical record must document additional information beyond the M1200 score to substantiate the limitation in vision before you can list a 369.xx code.

Why? M1200 doesn't test the patient's visual acuity, just his functional vision. Functional vision can be impaired by things like a halo or collar, range of motion problems, or periorbital swelling, Sparks says. These conditions would impact the M1200 score, but they don't support use of a 369.xx diagnosis code. Listing a 369.xx code requires documentation of specific parameters involving loss of visual field or acuity that optometrists or ophthalmologists use in their assignment.

Add Impairment Dx to 369.xx

Before you list a 369.xx code, look for clinical documentation that indicates loss of vision in one or both eyes. And verify the diagnosis with the physician. With proper documentation, you can list a 369.xx code along with an ophthalmic diagnosis such as glaucoma, retinal detachment, or cataract to define the patient's level of visual impairment.

You shouldn't list a 369.xx code just because the patient cannot see, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. The 369.xx category codes include vision acuity with correction but they exclude vision problems that are considered common refractive errors. For example, if your patient is farsighted and needs reading glasses, even if they don't have any, it's not appropriate to use the 369.xx codes. Look carefully at the Excludes note at the 369.xx codes.

Only list a 369.xx code when the patient has blindness or some other condition like retinopathy, glaucoma, cataracts, hemianopsia that is causing the vision impairment, says Selman-Holman. Always make sure that if you are coding vision loss or low vision, that you also code the reason for the vision problem.

Coding example: Your patient was admitted for problems controlling her hypertension. She recently experienced an exacerbation of chronic obstructive pulmonary disease (COPD) and is dyspneic on exertion. She lives alone and is legally blind due to glaucoma. For this patient, list the following codes:

  • M1020a: 401.9 (Essential hypertension; unspecified);
  • M1022b: 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation);
  • M1022b: 365.9 (Unspecified glaucoma); and
  • M1022c: 369.4 (Legal blindness, as defined in the U.S.A.).

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