Ophthalmology and Optometry Coding Alert

Find the facts facilitating foolproof reporting of AMD cases.

Nearly 20 million people in the United States are living with age-related macular degeneration (AMD), one of the leading causes of vision loss in people over 40. Given the continued uptick in the prevalence of AMD, ophthalmologists must be well-versed in the various types of macular degeneration and the proper way to document this common disorder.

With cases on the rise, now’s the time to get answers to any questions you might have about how to code and bill AMD correctly. Kick your AMD coding expertise up a notch with these quick tips and expert advice.

Let AMD Type Drive Dx Code Choice

Macular degeneration occurs when the small central portion of the retina, known as the macula, deteriorates. Your ophthalmologist will diagnose it as either dry or wet AMD. Knowing the type present in the patient will help you narrow down to the right AMD ICD-10 code.

Dry: If the patient suffers from nonexudative — otherwise known as dry, non-neovascular, or atrophic — AMD, report H35.31- (Nonexudative age-related macular degeneration). In dry AMD, yellowish cellular debris, called drusen, accumulates, which can cause retinal atrophy and scarring. Dry AMD is more common and less severe but can lead to the more severe wet AMD over time, as more drusen is deposited.

Wet: If the patient suffers from exudative — also known as wet, disciform, or neovascular — AMD, report H35.32- (Exudative age-related macular degeneration). In wet AMD, which is more severe than the dry form, tiny abnormal blood vessels form and leak fluid and blood, which distorts vision. Eventually, blood vessel bleeding creates a scar, which results in a permanent loss of central vision.

Other possibilities: ICD-10 includes two more diagnosis choices for AMD, though you won’t rely on them as often. Code H35.30 (Unspecified macular degeneration) isn’t normally used because the physician can typically tell what type it is based on their examination. Alternatively, you’ll report H35.35- (Cystoid macular degeneration) if there is swelling and a cyst in the macula, says Maggie M. Mac, CPC, CEMC, CDEO, AAPC Fellow, CHC, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida.

Complete the Code Using Laterality, Staging Info

To arrive at the complete, correct AMD ICD-10 code you must scour the documentation for information on the eye(s) affected and disease staging.

Laterality – When you report the codes for dry AMD (H35.31-) and wet AMD (H35.32-), you must include a 6th character to indicate laterality: 1 - right eye, 2 - left eye, 3 - bilateral.

Coding tip: When a patient is undergoing treatment, if the same disease stage is present in both eyes, use the bilateral designation “3” regardless of whether the physician is treating one or both eyes. The procedure code you report should indicate which eye your provider is treating.

Staging – There are three stages of AMD: early, intermediate, and late.

Dry: The codes for dry AMD (H35.31xx) use the 6th character to indicate laterality and the 7th character to indicate staging as follows:

• Early dry AMD: H35.31x1 – includes abnormalities of the retinal pigment epithelium (RPE), multiple small drusen (≤ 63 μm), and/or a few intermediate drusen (> 63 μm and ≤ 124 μm).
• Intermediate dry AMD: H35.31x2 – involves at least 1 large drusen (≥ 125 μm) or extensive intermediate drusen.
• Advanced atrophic dry AMD without subfoveal involvement: H35.31x3 – geographic atrophy (GA) not involving the center of the fovea.
• Advanced atrophic dry AMD with subfoveal involvement H35.31x4: – GA involving the foveal center.

GA defined: The advanced form of non-neovascular AMD — Central geographic atrophy (GA) — will have one or more zones of well-demarcated RPE and/or choriocapillaris atrophy. Drusen and other pigmentary abnormalities may surround the atrophic areas.

Wet: The codes for wet AMD (H35.32xx) use the 6th character to indicate laterality and the 7th character to indicate staging as follows:

• Active choroidal neovascularization (CNV): H35.32x1 – involves either:

o An AMD-related CNV lesion that shows disease activity (i.e., presence of intraretinal fluid (IRF) or subretinal fluid (SRF)) contributing to the patient’s visual impairment or

o An AMD-related CNV lesion that does not show disease activity (no IRF or SRF) in the presence of regular anti-vascular endothelial growth factor (VEGF) injections but shows recurrence of the disease activity (i.e., IRF/SRF) when anti-VEGF therapy is not given at appropriate intervals.

• Inactive CNV: H35.32x2 – refers to a CNV lesion associated with AMD that no longer exhibits disease activity (i.e., absence of IRF or SRF) and is a contributing factor in the patient’s visual impairment. Note an eye can have active CNV after the diagnosis of inactive CNV, and your provider can consider treatment at the time of active CNV.
• Inactive scar: H35.32x3 – entails an AMD-related CNV lesion that has developed into a disciform scar, causing visual impairment. The CNV lesion may or may not show disease activity (i.e., IRF/SRF), but it is deemed visually insignificant given the underlying disciform scar. Note an eye that has an inactive scar could have active CNV after the diagnosis of an inactive scar, and your provider can consider treatment at the time of active CNV.

Choose Your Visit Code Carefully

Ophthalmologists have the choice of using either eye codes 92002-92014 (Ophthalmological services: medical examination and evaluation …) or outpatient E/M codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …) for their AMD evaluations.

Some Medicare payers have local coverage determination policies on the eye codes, with specific guidelines as to what needs to take place to use the eye codes. Some states also have policies on the specific elements that must be performed for comprehensive eye exams. “These often mirror the elements of an eye exam described in the CPT^® book,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Other Medicare payers do not have such policies. When that is the case, physicians should use the CPT^® book as a guideline for what needs to take place to qualify for an intermediate or comprehensive eye exam. “This language is not part of the code descriptors; refer to the language at the beginning of the Ophthalmology section of CPT^®, before the discussion of ‘General Ophtalmological Services,’” Johnson notes.

Resource: www.aao.org/eyenet/article/how-to-use-the-icd-10- codes-for-amd