Ophthalmology and Optometry Coding Alert

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.

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 of specificity?

According to CMS, there has been some confusion defining ICD-9 codes that are to the "highest degree of specificity." In part, this confusion stems from the fact that diagnosis codes can be composed of three, four or five digits, depending on your physician's documentation. CMS advocates using the following guidelines to assign diagnosis codes that most fully explain the narrative description of the symptom of diagnosis coding: Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided to provide greater specificity.

Assign three-digit codes only if there are no four-digit codes within that code category. Assign four-digit codes only if there is no fifth-digit subclassification for that category. Assign the fifth-digit subclassification code for those categories where it exists.

One thing you should not do, Callaway says, is indicate on the claim that it was a "normal exam" just because the physician didn't find anything you won't get paid without battling with the insurance company and sending in medical records to prove the patient had a medical complaint. And never code what the physician thinks or suspects the problem is, because this is not proper diagnosis coding behavior, she warns coders.

You are more likely to be reimbursed by Medicare as well as many third-party payers when you list symptoms or complaints as primary diagnosis codes for an evaluation, because a definitive diagnosis gives the carrier a reason to say, "No, we don't cover that service for that diagnosis," Callaway says.

According to CMS Program Memorandum AB-01-144, Medicare has taken the following stance on assigning diagnosis codes for diagnostic services: