Ophthalmology and Optometry Coding Alert

Selecting the correct diagnosis code or codes to link to a procedure depends partly on the patient's chief complaint. Coders must know when to rely on the chief complaint and when to rely on the final diagnosis for each procedure or service. In ophthalmology, when so many minor procedures are done at the same time as an office visit, it's essential to choose ICD-9 codes that are as accurate and specific as possible. The diagnosis gets the claim paid, and an incorrect diagnosis may lead to rejection of a claim for lack of medical necessity. Choose a diagnosis based on the information obtained, not just to get paid that is fraud.
 
Only a physician can choose the diagnosis. However, the chief complaint an essential part of office visit coding is often documented by the technician, who, in ophthalmology, often conducts an extensive interview with the patient prior to the doctor's examination, and elicits the chief complaint.
 
But sometimes the chief complaint surfaces after the technician interview. Perhaps, during a test or the ophthalmologist's examination, the patient recalls a problem. Therefore, many consultants recommend leaving the chief complaint blank until after the examination if the patient does not offer one during the history, says Sherry Searson, CPC, an independent coding and billing ophthalmology consultant in Charleston, S.C.

Frequently, the chief complaint code and the diagnosis code are different but related. For example, a patient may complain of pain in the eye (379.91, unspecified disorder of eye and adnexa; pain in or around eye), and the physician discovers a significantly elevated intraocular pressure (IOP) (365.xx). The elevated pressure is causing the pain. The billing diagnosis should always be the definitive diagnosis, if there is one, unless the patient has no complaint at all.

Sometimes the diagnosis for an office visit is entirely different from the reason that the patient came to the office. For example, a patient complains of dry itchy eyelids. The technician, noticing that the patient's last visit was almost a year ago, asks other questions unrelated to the eyelids, including general vision questions. The patient says, "Oh yes, in fact I am having a problem driving at night it's the glare." There are two chief complaints. The ophthalmologist, based on the vision complaint, performs a complete eye exam (92014) and discovers incipient cataracts. The physician also treats the eyelid problem, which is caused by blepharitis. Use the vision problem (368.xx, visual disturbances) as the primary diagnosis, and the blepharitis as the secondary diagnosis (373.0x). Without the chief complaint of vision problems, the physician would have only performed a problem-focused visit, billing 99212 or perhaps 99213. (And the patient's cataracts would have been undiscovered.) This illustrates the importance of capturing a good history.

Use the definitive diagnosis to file the claim; if there isn't one, use the symptom. If a patient complains of a foreign-body sensation, but nothing is there, nothing can be removed. However, you can still code the office visit with a complaint of pain in or around the eye (379.91), says John Bell, CEO of Maine Eye Care in Waterville.

If there is no symptom, but the visit is a doctor-recommended recall for a known diagnostic condition, the visit is covered. Indicate the condition as the reason for the visit. For example, "recheck for glaucoma (365.xx) and cataracts (366.xx), oculus uterque (OU) (both eyes)."

In a more complicated recall example, an established patient comes in for conjunctivitis. The ophthalmologist examines the patient and prescribes an antibiotic, billing 99213 with the appropriate conjunctivitis diagnosis code (372.xx). Ten days later, the patient returns for a recheck. The technician interviews the patient first, as always. Now that the patient's conjunctivitis has cleared up, the technician asks about other eye symptoms. The patient's eyes feel dry and then become watery when he's reading at night. The reason for the visit was a conjunctivitis follow-up, but an entirely different chief complaint drives the visit.
 
"The dryness and subsequent watery eyes become the chief complaint for the visit," Searson says. The ophthalmologist performs a comprehensive eye exam, which the patient hasn't had in over a year, instead of just a recheck. The recheck will be incorporated into the eye exam (92014) with 375.15 (other disorders of lacrimal gland; tear film insufficiency, unspecified).