ICD 10 Coding Alert
Don’t Confuse Patient History With Current Diagnosis
Question: Our practice just brought in a new physician and every time they perform cataract surgery on a patient, they circle Z98.4 as the code to report for the service. Is this correct? Kansas Subscriber Answer: When you’re coding for the actual cataract surgery, it would not be appropriate to report anything from the Z98.4- (Cataract extraction status) code group. Those codes are typically reserved to describe patients with a history of cataract surgery. If the physician saw a patient who’d had cataract surgery in the past, then came in postoperatively or later for a follow-up or a problem that may be affected by the prior surgery, then you would use a Z98.4- code. When you’re coding for a cataract evaluation or the actual surgical procedure, as your question suggests, you would use one of the cataract diagnosis codes from the H25 (Age-related cataract) or H26 (Other cataract) families, depending on the specifics in the documentation.
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