Ophthalmology and Optometry Coding Alert

Hint: Not all cataracts are age-related.

The calendar is about to turn to a new year, but that doesn’t mean you have to learn another entirely new set of diagnosis coding guidelines. However, it is an excellent time to nail down your knowledge of ICD-10 coding, so we’ve put together a few questions that can allow you to test your prowess.

Check out these three eye-care-focused scenarios and determine whether you can select the right code for the services.

Know the Glaucoma Stage Before You Code

Question 1: Your ophthalmologist sees a glaucoma patient at your practice who has low-tension glaucoma of the left eye, and you report H40.12 (Low-tension glaucoma). Even though you’ve coded the service out to five characters, your payer still denies the claim. What went wrong?

Solution 1: Coding out to five characters may make you feel like you’ve done a thorough job, but this code requires a few more numbers before your payer will approve it. In reality, your ICD-10 code must reflect not only the condition, but also the affected eye and the glaucoma stage.

Even if you don’t know the glaucoma stage, you should document that information as well using the “unspecified stage” character, which is “0,” says Gina Vanderwall, OCS, CMBS, CPC, CPPM, CPC-I, MFG coding educator with the University of Rochester Medical Center in Rochester, New York. Therefore, for this situation, the correct code would be H40.1220 (Low-tension glaucoma, left eye, unspecified stage).

If, however, you do know the stage, you’ll assign the appropriate seventh character digit. The options are:

• 0: Stage unspecified
• 1: Mild Stage
• 2: Moderate stage
• 3: Severe stage
• 4: Indeterminate stage

Choose the stage that best reflects the documentation and assign that as the final character in your ICD-10 code.

Blepharitis Presents in More Than 1 Way

Question 2: A patient presents to your optometrist with itchy, dry eyes that are often red and swollen. The provider diagnoses the patient with blepharitis affecting the right upper eyelid and the left lower eyelid. You don’t see any documentation of the blepharitis type, so which code applies?

Solution 2: Blepharitis (H01.0x) 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. The ICD-10 code set offers you multiple options when coding this condition, most of which require you to know the type of blepharitis affecting the patient’s eyes.

Blepharitis occurs in several variations, and the three that you’ll see most frequently in your medical charts are ulcerative, squamous, and unspecified. Ulcerative blepharitis (H01.01x) typically has lesions and small ulcerated regions along the eyelid margins, while squamous blepharitis (H01.02x) manifests in small white or gray scales along the eyelid’s edge. When the doctor doesn’t specify which type of blepharitis the patient has, you’ll typically report unspecified blepharitis (H01.00x).

Once you confirm that the patient has a specific type of blepharitis, you’ll then expand the codes out to the sixth digit by determining the location of the blepharitis. For instance, unspecified bilateral blepharitis of the right upper eyelid and the left lower eyelid, as described in the question, would be coded as H01.001 (Unspecified blepharitis, right upper eyelid) and H01.005 (Unspecified blepharitis, left lower eyelid), respectively. You’d submit both codes on the claim because they describe different eyes.

Turn to H26 Section for Juvenile Cataracts

Question 3: A 10-year-old patient reports to the practice with poor vision in both eyes and her mother said her eyes “look cloudy.” The ophthalmologist examines the patient and diagnoses her with bilateral cortical cataracts. Which code applies?

Solution 3: In this situation, you’ll have to go beyond the standard age-related cataract coding options, and instead you’ll look to the “Infantile and juvenile cataract” section of ICD-10 (H26.0) and scroll down until you find the “Infantile and juvenile cortical, lamellar, or zonular cataract” range (H26.01).

Because the patient’s cortical cataracts affect both eyes, you’ll select H26.013 (Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral).