ICD 10 Coding Alert
Find the Right Code, Even When the Diagnosis Is Vague
Hint: If patient suspects foreign body but ophthalmologist can’t find, code eye pain. You don’t have to have a clear-cut final diagnosis handed to you on a silver-plated electronic medical record (EMR) to find a code that accurately describes the reason for an encounter — and staves off denials. Consider these scenarios and how to find the right ICD-10 code even when blurry vision, dry eyes, or suspicion of a foreign body don’t seem to yield concrete results. Seek Correct Code for Blurred Vision Some coders say that when patients present with blurred vision, they turn to H53.8 (Other visual disturbances). Many insurance carriers don’t agree, however, using the logic that there must be something causing the “disturbance,” and insisting you report the cause, not the symptom. Coding tip: If a patient has a medical problem, use the final diagnosis; if the patient has only blurred vision, use H53.8. Example: A patient presents with a complaint of blurry vision, and the ophthalmologist finds a cataract. Report cataract (such as a code from the H25 series) as the primary diagnosis. If the patient doesn’t specifically complain of blurred vision, but instead asks for a routine eye exam, it gets a little trickier. How you code may depend on the insurance, according to experts. If the patient is coming in for a routine vision exam and you know you’re going to bill vision insurance, report it with an eye encounter code, such as Z01.00 (Encounter for examination of eyes and vision without abnormal findings). Know These Dry Eye Codes “Dry-eye syndrome” is usually caused by problems with the lacrimal gland (tears). The most common diagnosis code associated with dry eye is H04.12 (Dry eye syndrome). Another diagnosis you might see is H16.229 (Keratoconjunctivitis sicca, not specified as Sjogren’s, unspecified eye). Warning: Some coders believe they can use H04.12 and H16.149 (Punctate keratitis, unspecified eye) interchangeably, but this is not true. If a patient presents with punctate keratitis and the ophthalmologist determines that dry-eye syndrome is the cause, report H04.12. If the patient’s dry eyes are caused by punctate keratitis, you’ll instead report H16.149. Understand Scope of Foreign-Body Codes A patient who presents with a foreign-body (FB) sensation (i.e., the feeling that there’s something in their eye) causes no coding problems — as long as there actually is something in their eye. The T15 series (Foreign body on external eye) covers foreign bodies on the external eye; look at codes such as S05.40XA (Penetrating wound of orbit with or without foreign body, unspecified eye, initial encounter) or S05.50XA (Penetrating wound with foreign body of unspecified eyeball, initial encounter) for penetrating wounds. If the ophthalmologist removes FBs from different anatomical parts of the same eye, however, then you can report a pair of codes, say experts. Example: The ophthalmologist removes a superficial conjunctival FB and a corneal FB from a patient’s eye; evidence of slit lamp use is in the notes. On the claim, you would report the following: Coding tip: What if the patient complains of a foreign-body sensation, but the ophthalmologist’s exam finds no sign of a foreign body or penetrating substance? Code the complaint — pain in and around the eye — experts say. Key: If it is a foreign-body complaint, chances are the patient is in some kind of pain, and if the pain cannot be attributed to something specific, you have the option of using an unspecified eye-pain code, such as H57.13 (Ocular pain, bilateral) or a code representing a specific result of the pain. For example, if the foreign-body sensation resulted in inflammation, you can use S05.00XA (Injury of conjunctiva and corneal abrasion without foreign body, unspecified eye, initial encounter) for corneal abrasion or S05.00XA (Injury of conjunctiva and corneal abrasion without foreign body, unspecified eye, initial encounter) for conjunctival abrasion. Another possible cause for a foreign-body sensation is dry-eye syndrome. If the patient has dry-eye syndrome, you should report that code.
Related Articles
ICD 10 Coding Alert
- Diagnosis Deep Dive:
Boost Your Knowledge to Code This Common Cancer Complication
Knowing which diagnosis came first is key to finding the correct guidelines. Many people living [...] - Best Practices:
Find the Right Code, Even When the Diagnosis Is Vague
Hint: If patient suspects foreign body but ophthalmologist can’t find, code eye pain. You don’t [...] - Specialty Spotlight:
Demystify Perinatal Period Codes With This Advice
Surprise: Sometimes the code you need isn’t in ICD-10-CM Chapter 16. Coders whose work focuses [...] - You Be the Coder:
Note Any Underlying Conditions Along with Diagnosis for G47.3
Question: A patient’s general practitioner referred them to our pulmonology practice after they discussed the [...] - Reader Questions:
Note Which Syndromes Are Synonymous With Particular Stroke
Question: Notes indicate that a patient suffered from Wallenberg syndrome. I’m not familiar with this term [...] - Reader Questions:
Shoveling Injury? There’s a Code for That
Question: A patient came into our practice complaining of right shoulder pain after shoveling snow off [...] - Reader Questions:
Look Beyond ICD-10-CM for This Rare Cancer
Question: How do you code triple-hit lymphoma with MYC, BCL2, and BCL rearrangements? The provider selected [...] - Reader Questions:
The Rules Aren’t Clear for This Age-Old Question
Question: Are there any ICD-10 guidelines for when to use a code that is specific to [...] - Reader Questions:
Whether Gout or Podagra, Look to M10.-
Question: Encounter notes indicate that the provider performed a level-two office evaluation and management (E/M) service [...]
