Ophthalmology and Optometry Coding Alert

Understand who’s at risk, know the screening rules, and specify which eye is affected to nail the proper ICD-10 code.

As the second most common cause of blindness in the United States, glaucoma has certainly made its mark on the population – and has doubtlessly impacted your practice. Here are a few basics to get you up to speed on this common disease, the different methods of detection and treatment, and your coding options.

What Is Glaucoma?

Glaucoma is a disease that damages the optic nerve, usually when fluid builds up in the front (anterior) part of the eye, according to the American Academy of Ophthalmology. The extra fluid increases pressure, damaging the optic nerve.

The disease, which affects nearly 3 million Americans, has two types, explains Alice Marie Reybitz, RN, BA, CPC, COC, CPC-I, CCS-P, Online Elearning Instructor for the American Academy of Professional Coders (AAPC), who led a seminar on the subject at CodingCon 2015:

Open-Angle: The most common, type, it occurs when the drainage system of the trabecular mesh is clogged and the fluid that lubricates the eye cannot flow freely and the pressure builds up, Reybitz explains. Ophthalmologists can only detect open-angle glaucoma by measuring the ocular pressure.

Closed-Angle: This type affects a small percentage of patients, Reybitz says. Onset can be slow or quick, which makes this the most dangerous type. Closed-angle glaucoma “is found in many farsighted individuals in which the anterior chambers are already narrowed, and the angle at which the fluid would circulate narrows considerably,” she says.

Who Is at Risk?

Those at risk include, Reybitz says:

• The very nearsighted
• The very farsighted (for narrow-angle)
• Hypertensive patients
• Prolonged steroid users
• Those with a family history
• Sufferers of trauma and eye injury
• Diabetics
• Those showing increased intraocular pressure
• African-American
• Those with a history of severe anemia.

How Do I Code Screenings?

Screening Coverage: Medicare and most commercial insurers cover annual screenings for those determined to be at high risk:

• Diabetics
• Those with a family history of glaucoma
• African-Americans older than 50
• Hispanics older than 65.

Diagnosis Codes: ICD-10 code Z13.5 (Encounter for screening for eye and ear disorders) is the diagnosis code to use for a glaucoma screening, Reybitz says. A secondary diagnosis would help smooth the path for the claim, she adds:

• E10-E13 for the appropriate diabetes diagnosis (e.g., E11.3, Type 2 diabetes mellitus with ophthalmic complications)
• Z82.1 (Family history of blindness and visual loss)
• Z83.511 (Family history of glaucoma)
• Z15.89 (Genetic susceptibility to other disease).

What If the Ophthalmologist Finds Glaucoma?

Look to the H40.00-H42 (Glaucoma) family, says Reybitz – adding that what was a set of 43 codes under ICD-9 early last year has expanded to 238 codes under ICD-10. With the added specificity of the diagnosis codes, the ophthalmologist’s documentation must back up the reported code, she warns.

Seventh Characters: In many of the glaucoma codes, the seventh character describes the stage of the glaucoma:

• 0 – unspecified
• 1 – mild
• 2 – moderate
• 3 – severe
• 4 – indeterminate.

Example: ICD-10 code H40.31X1 (Glaucoma secondary to eye trauma, right eye, mild stage) describes a specific condition with a mild stage in a specific eye, which must be specified in the documentation. The same condition in the same eye at a moderate stage would be coded H40.31X2 (Glaucoma secondary to eye trauma, right eye, moderate stage).

Don’t miss: When a patient presents with the same type and stage in both eyes, report only the code for that type of glaucoma, bilateral, with the seventh character for the stage.

Example: A patient has moderate chronic angle-closure glaucoma in both eyes. You would report ICD-10 code H40.2232 (Chronic angle-closure glaucoma, bilateral, moderate stage).

However: If a patient presents with a type of glaucoma for which there is no bilateral code (H40.10-H40.11 and H40.20), use the code for the type of glaucoma with the seventh digit representing the stage.

Example: A patient has severe primary open-angle glaucoma. No matter whether he has it in one eye, both eyes, or unspecified eyes, report H40.11X3 (Primary open-angle glaucoma, severe stage).

If a patient is admitted with one stage and it worsens during his stage, code the highest stage documented, Reybitz advises. And “unspecified” and “indeterminate” are not interchangeable, she warns: “4” is used for clinically based indeterminate type, which must be documented; “0” is used in cases where the stage is not mentioned in the documentation.

There’s more: Check with Ophthalmology Coding Alert next month for Part II, which will cover CPT^® codes for screening, testing, and treatment.