Ophthalmology and Optometry Coding Alert

Scratch that spring allergy coding itch with this expert advice.

Spring is here, which means you're probably seeing your share of patients with eyes irritated from allergies. What's the best diagnosis code? It depends on the specific condition.

Get Specific With 3 Key Conditions

For your claims to be processed successfully, you must report the most specific diagnosis code available for the patient's eye irritation. Most patients you see with eye irritations will have one of three major conditions:

1. Blepharitis (373.0x): This is an inflammation of the eyelids, particularly at the lid margins, caused by an overgrowth of bacteria in the skin, typically associated with a low-grade bacterial infection or a generalized skin condition.

Blepharitis occurs in two forms: anterior and posterior blepharitis. The anterior type affects the outside front of the eyelid where the eyelashes are attached. The two most common causes are scalp dandruff and bacteria. Posterior blepharitis affects the inner eyelid and is caused by problems with the oil (meibomian) glands in the eyelid. Two skin disorders are the cause: acne rosacea and scalp dandruff.

Tip: Seventy percent of dry eye patients also have blepharitis. So don't overlook coding for both conditions if both are present. A complete diagnostic picture will help the payer understand the medical necessity of the treatments chosen, which in turn will facilitate getting your claims paid.

2. Dry eye (375.15): This is caused by decreased production of fluids from tear glands, which destabilizes the natural tear film, allowing it to break down rapidly and create dry spots on the eye surface, according to www.mayoclinic.com.

An imbalance in the substances that make up the tear film also causes dry eyes. Treatment of dry eye aims to restore a more normal tear film to minimize dryness, blurred vision, and discomfort.

3. Conjunctivitis (372.xx): Otherwise referred to as allergic disease or "pink eye," this ailment is characterized by redness and inflammation of the membranes (conjunctiva) covering the whites of the eyes and the membranes on the inner part of the eyelids.

These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents, as well as to underlying diseases within the body. Viral and bacterial forms of conjunctivitis are common in childhood, but they can occur in people of any age.

Consider Primary Reason for Visit

Experts advise: If the primary diagnosis is a routine check-up and blepharitis or conjunctivitis is a secondary finding, the practice should still code for a routine visit.

Example: A new patient comes in for a routine eye exam. The optometrist performs a comprehensive exam and discovers tear film insufficiency. Report 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits), and link it to V72.0 (Examination of eyes and vision). As a secondary diagnosis, report the dry eye with 375.15 (Tear film insufficiency, unspecified).

If the primary reason for a new or subsequent visit is medical, then the office crosswalks to the minor evaluation and management (E/M) codes -- 99201-99215 -- leaving the 92000 codes behind. The E/M codes require specific levels of history, examination, and medical decision making, but the 920xx codes do not have those requirements.

However: "The eye codes do expect the physician to obtain and document a patient history that is related to issues concerning the eyes," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital Ambulatory and Network Oversight at the Mount Sinai Medical Center Compliance Department in New York City. Examples include personal history of eye surgery, chronic irritation, dry eye, and contact use, she says. "The family history should include a notation of glaucoma or other eye-related problems with family members, while the social history should indicate things such as 'works as a computer programmer,' which may relate to problems associated with the eye."

Important: This means that you may need to focus on taking a more complete history to support submitting codes in the 99201-99215 range. You must also document the extent of your examination and the complexity of your medical decision making.

Remember: All E/M documentation must include a chief complaint, says Carrie Weiss, senior provider education consultant with Palmetto GBA, a Part B MAC in seven states. "The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter," she explains. "It is typically stated in the patient's own words."

Example: A patient with chronic blepharitis (373.00, Blepharitis, unspecified) comes in due to a recent foreign body sensation. During the history intake, the patient mentions a recurring headache (784.0, Headache). The patient had an unremarkable comprehensive exam four months ago, and the ophthalmologist doesn't think it's necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye (930.0, Corneal foreign body). Refraction indicates a significant increase in hyperopia (367.0, Hypermetropia), which may explain the headache.

You can report an E/M code -- as long as you meet the documentation guidelines for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined with the E/M codes that are not as specific with the eye codes.