Ophthalmology and Optometry Coding Alert

Don’t skimp on coding when you see a patient with an urgent diagnosis.

Although most eye care practices see most of their patients for pre-planned services, the reality is that ophthalmologists and optometrists also treat patients with urgent eye conditions. These may not be the standard diagnoses you’re accustomed to reporting, but billing them requires just as much accuracy as any other condition.

Check these eye trauma scenarios and determine if you know how to code the diagnoses before reading our expert advice.

Get Specific for Retinal Detachment

Question: A 57-year-old patient presents complaining of seeing floaters in one part of their right eye, with vision blurred in that area. They say they were in a bicycle accident three weeks prior and these symptoms have worsened over time since that happened. The physician suspects retinal detachment, but upon examination, diagnoses the patient with a horseshoe retina tear with no detachment. You report a code from the H33.0 (Retinal detachment with retinal break) section, but the claim is denied. What went wrong?

Answer: Because the physician suspected a detached retina but ultimately did not diagnose the patient with one, you should avoid the retinal detachment codes in this situation. The ICD-10-CM Guidelines are clear about the fact that you should never report suspected diagnoses on your claim. Instead, you should report the code for a horseshoe tear of the retina without an actual detachment.

Because the patient’s right eye was affected, you’ll report H33.311 (Horseshoe tear of retina without detachment, right eye) for this situation. If you can directly correlate the tear to the bicycle injury, you can also report an external cause of injury code to describe the bike accident, such as V18.0XXA (Pedal cycle driver injured in noncollision transport accident in nontraffic accident…).

Sequence These Orbital Fracture Codes

Question: A patient presents with multiple specified fractures on the same orbit. Should you use one diagnosis code, or code each specific fracture on the same orbit?

Answer: The answer will depend on how the physician documents the fractures in the record, says Gina Vanderwall, OCS, CMBS, CPC, CPPM, CPC-I, MFG coding educator with the University of Rochester Medical Center in Rochester, New York. ICD-10-CM Guidelines indicate, “Multiple fractures are sequenced in accordance with the severity of the fracture.”

If the physician has just evaluated the patient for the fractures to make sure no surgery is indicated, the most severe fracture would be sequenced first, with the remaining fractures coded in hierarchical order, and should link the diagnosis code(s) to the applicable E/M code, Vanderwall says.

If the physician surgically treats one of the specific fractures, then you’ll link the fracture care code to the diagnosis for the fracture treated during the surgery.

For instance, if a patient presented to the ED with a severe fracture of the medial orbital wall of the right eye and a mild fracture of the lateral orbital wall of the right eye, then you would report the following diagnosis codes:

• S02.831A (Fracture of medial orbital wall, right side, initial encounter for closed fracture)
• S02.841A (Fracture of lateral orbital wall, right side, initial encounter for closed fracture)

The medial orbital wall fracture is listed first since the severity of that injury is greater than that of the lateral orbital wall. If you know the cause of the injury, you can also report another code to describe the source of the injury.

Consider How to Report Ocular Hemorrhage

Question: A patient presents to the office with his left eye completely filled with blood after accidentally poking his eye with a pen. The patient does not report any pain associated with the injury. The physician diagnoses the patient with a subconjunctival hemorrhage. Which code applies?

Answer: For a conjunctival or subconjunctival hemorrhage, you’ll refer to the same code series, which is the H11.3 range (Conjunctival hemorrhage). These must be coded out to the fifth character, which requires you to also add another character to denote which eye was affected.

In this case, the hemorrhage occurred in the patient’s left eye, so you’ll report H11.32 (Conjunctival hemorrhage, left eye).