Ophthalmology and Optometry Coding Alert

When a patient comes in with a complaint but the suspected diagnosis comes out negative, what should you do? Ophthalmology coders are constantly facing the diagnosis-coding dilemma of a patient presenting with symptoms of a condition that the results of testing confirm he doesn't have. And it's patients who present with foreign-body sensation who are often at the source of the diagnosis-coding quandary. Here we'll answer your most frequently asked questions about coding foreign-body sensation for appropriate reimbursement. What is proper diagnosis coding if a patient comes in with a foreign-body sensation and an exam shows no sign of a foreign body or irritating substance? Diagnosis coding is one of the few activities where a complaint will actually get you somewhere. Although many physicians feel the need to provide a definitive diagnosis when submitting a claim, there are many circumstances in which the symptom the patient presented with is the only thing they can find.

Proper diagnosis coding requires you to code the reason patients came in the door, not necessarily what you found when they get there, says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. "The patient's perception of the problem is a perfectly valid reason for performing an exam, and the fact that you examine them and find nothing doesn't mean that the suspected diagnosis isn't what the ophthalmologist was looking for and trying to treat."

You need to give the patient's chart a thorough once-over, because you may discover that the patient has dry-eye syndrome, for example, a possible cause of foreign-body sensation, says Nina Bagley, CPC, coding specialist for J. Michael Geiger, MD, in Fayetteville, N.C. In this case, you would use a diagnosis code for dry-eye syndrome, she adds. 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, Bagley says. For example, if the foreign-body sensation resulted in inflammation, you can use 918.1 for corneal abrasion or 918.2, conjunctival abrasion. Will we still get paid for an exam that does not confirm a condition? When it comes to getting paid for an exam that doesn't yield a definitive diagnosis, carriers won't give you much trouble if you code carefully. Try to give the most specific diagnosis possible when billing private payers to avoid any claims delays or denials, Bagley says. But how do you know if the diagnosis code you chose is to the highest degree [...]