Ophthalmology and Optometry Coding Alert

Knowing the right codes to report for blurry vision can save your practice from costly denials

When a patient presents with vague, generalized complaints -- such as blurry vision, dry eyes or a foreign-body sensation -- it can sometimes be challenging to coders. Our experts explain how to handle three common complaints.

If someone's vision is blurred, his first visit will probably be to an eye-care specialist. Yet ICD-9 codes that specifically describe blurred vision, and similar diagnoses that relate to refractive error, sometimes aren't covered. What's a coder to do? An option many coders choose is to report 368.8 (Visual disturbances; other specified visual disturbances).

The ICD-9 manual includes the note "blurred vision NOS (not otherwise specified)," indicating that this is a good choice for blurred vision. Some carriers don't agree, however, using the logic that there must be something causing the blurriness and insisting you report the cause, not the symptom.

Coder's Rule: If a patient has a medical problem, use the final diagnosis; if the patient has only blurred vision, use 368.8, says Davina Luciano, CPC, coder for Inland Eye Specialists in Hemet, Calif. For example, "If a patient comes in with a complaint of blurry vision, and the ophthalmologist finds a cataract, we use cataract (366.xx) as the primary diagnosis and blurred vision (368.8) as the secondary diagnosis," she says.

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 "depends on the insurance," says Rita Knapp, CPC, coding specialist with Whitson Abrams Vision and Laser Centers in Indianapolis. "If the patient is coming in for a routine vision exam and we know we're going to bill a vision insurance, we would go ahead and bill with a routine diagnostic code for refractive error [367.x]. If the patient doesn't have a vision plan, then we probably would bill with 368.8."

Snag: Medicare's Routine Services Policy excludes coverage of routine eye exams or to correct refractive error. "The coverage of services rendered by an ophthalmologist is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition," the policy states. "When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed."

LMRPs vary in which diagnosis codes are covered. Trailblazer, Medicare's contractor for Colorado, New Mexico and Texas, does not cover any of the 367.x codes. Meanwhile, Palmetto GBA(West Virginia) considers 367.0-367.4 (including diagnoses such as myopia, astigmatism and presbyopia) noncovered codes, but will accept codes from the 367.5x series (Disorders of accommodation).

Some coders report that when billing with a symptom code, such as 368.8, their carrier also requires the use of V80.2 (Special screening for neurological, eye, and ear diseases; other eye conditions). When in doubt, ask the carrier for its written policy and get the patient to sign an advance beneficiary notice.

"Dry-eye syndrome" is usually caused by problems with the lacrimal gland (tears). The most common diagnosis code associated with dry eye is 375.15 (Tear film insufficiency, unspecified), says Knapp. Another diagnosis you might see is 370.33 (Certain types of keratoconjunctivitis; keratoconjunctivitis sicca, not specified as Sjgren's).

Warning: Some coders believe they can use 375.15 and 370.21 (Superficial keratitis without conjunctivitis; punctate keratitis) 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 375.15. If dry-eye syndrome is not the cause, you should report 370.21.

A patient who presents with a foreign-body sensation (i.e., the feeling that there's something in his eye) presents no problems -- as long as there actually is something in his eye. The 930.x series covers foreign bodies on the external eye; look at 870.4 (Penetrating wound of orbit with foreign body), 871.5 (Penetration of eyeball with magnetic foreign body) and 871.6 (Penetration of eyeball with [nonmagnetic] foreign body) for penetrating wounds.

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, advises Knapp. "If the patient is really adamant about having this feeling, and yet we really can't find anything, we'll code for the pain in and around the eye," she says.

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 -- an eyelash, for example (374.05, Trichiasis without entropion) -- you have the option of using an unspecified eye-pain code, such as 379.91 (Pain in or around eye) or a code representing a specific result of the pain. For example, if the foreign-body sensation resulted in inflammation, you can use 918.1 (Superficial injury of eye and adnexa; cornea) for corneal abrasion or 918.2 (... conjunctiva) for conjunctival abrasion, says Knapp.

Swelling or redness may also be a side effect of the foreign body and may be coded with 379.92 (Unspecified disorder of eye and adnexa; swelling or mass of eye) or 379.93 (... redness or discharge of eye) respectively, says Maggie M. Mac, CMM, CPC, a health management consultant and national seminar leader for McVey Associates.

Another possible cause for a foreign-body sensation is dry-eye syndrome. If the patient has dry-eye syndrome, you should report that code.