Ophthalmology and Optometry Coding Alert

Often a patient with only a complaint of blurry vision will visit an ophthalmologist. However, no diagnosis code exists for blurred vision; furthermore, similar diagnoses that relate to refractive errors are not covered. A possible solution is to use 368.8 (Visual disturbances; other specified visual disturbances).

Some payers say 368.8 is insufficient. They require more than a symptom: If a patient has blurred vision, they reason, there is a cause either a refractive error (367.xx), which Medicare and most private medical plans will not cover, or a medical condition, which is covered.

In South Carolina, Palmetto GBA says that the patient's complaint should be used as the chief diagnosis unless the final diagnosis is related to the chief complaint. Some coders follow this simple rule: If a patient has a medical problem, use the final diagnosis; if the patient has only blurred vision, use 368.8. For example, if a patient comes in with a complaint of blurry vision, and you find a cataract, use cataract (366.xx) as the primary diagnosis and blurred vision (368.8) as the secondary diagnosis, says John Bell, CEO of Maine Eye Care of Waterville. If there is no cataract, code the symptom 368.8.

Many ophthalmologists believe they are supposed to use the chief complaint as the diagnosis because the Medicare Carriers Manual states that the patient's reason for the visit determines medical necessity. If a patient comes in with no complaint and insists that he or she wants only a routine checkup, even if you find a problem the visit isn't payable, regardless of what the examination reveals. This is a situation in which it is best to leave the chief complaint blank so the physician can ask the patient about symptoms related to the problem found in the examination.

If the patient indicates that he or she has had one or more of those symptoms or signs, the physician can document that in the history. Sometimes patients don't want to complain, so they don't mention such problems until the physician inquires. Payers are starting to scrutinize claims involving blurred vision, so the more information provided in the history and examination, the better.

"Tell patients up front that Medicare doesn't cover routine eye exams, and that if they just need glasses, they may have to pay for the visit," says Sherry Searson, CPC, an independent coding and billing ophthalmology consultant based in Charleston, S.C. When you're in doubt, she recommends asking the carrier for its written policy. In addition, obtain an advance beneficiary notice (ABN) from the patient to guarantee payment and bill any diagnostic tests to Medicare. Diagnostic tests will be covered if the doctor finds something that warrants such a test. For example, the ophthalmologist performs a pressure check as part of the examination and, based on elevated pressure (365.00), orders visual field tests (92081-92083). The visual field tests will be paid with the diagnosis of elevated intraocular pressure (IOP). The office visit can't be billed with IOP because it is unrelated to the patient's reason for the visit (blurred vision).

Four local medical review policies (LMRPs) say they will pay for 368.8, but none will pay for refractive error. If a patient comes in with blurred vision and the cause is refractive error, reporting the final diagnosis instead of the chief complaint will probably result in a denial.

Trailblazer will not pay for general ophthalmological services (92002-92014) with any refractive error. It will pay with 368.12 (Transient visual loss), 368.13 (Visual discomfort), 368.15 (Other visual distortions and entoptic phenomena), 368.8, V41.0 (Problems with special senses and other special functions; problems with sight), V41.1 ( other eye problems) and more than 1,000 other eye-related diagnoses.

Healthnow (Upstate Medicare, New York) and Empire Medicare (New York City area) will not pay for simple hypermetropia (367.0), myopia (367.1) or astigmatism (367.2x), but will pay for many other refractive error diagnosis codes, including 367.31 (Anisometropia), 367.32 (Aniseikonia), 367.51-367.53 (Disorders of accommodation), and 367.81-367.89 (Other disorders of refraction and accommodation). The New York carriers will pay for 368.00-368.03 (Visual disturbances), 368.10-368.16 (Subjective visual disturbances), 368.2 (Diplopia), 368.30-368.34 (Other disorders of binocular vision), 368.40-368.47 (Visual field defects), 368.51-368.59 (Color vision deficiencies), 368.60-368.69 (Night blindness), 368.8 and 368.9 (Unspecified visual disturbance) and many other diagnoses for 92002-92014.

Nationwide will pay with 368.00-379.99. It will not pay for any 367.xx diagnosis codes. It will pay for hundreds of other medical diagnoses.

Some physicians disregard the dictum that the original complaint must be used as the diagnosis; they argue that the diagnosis code should be the most specific. If there is no medical condition related to blurred vision and the final diagnosis is refractive error, the visit should be reported with the refractive error. If the patient has blurred vision but no related medical condition or refractive error that corrects the blurred vision, the blurred vision diagnosis must be used alone.