Ophthalmology and Optometry Coding Alert

Find out what to code – and what to leave off your claims.

Reporting ICD-10 codes isn’t always as cut and dried as transferring the diagnosis that the eye care specialist circled on the superbill to the claim and calling it a day. In reality, you may find multiple diagnosis codes that apply to your case and you aren’t always sure which you should report.

Strategy: By answering four important questions, you’ll avoid applying a definitive diagnosis prematurely -- which can have longstanding consequences for a patient and the patient’s insurance.

Danger: If you apply a diagnosis for a condition like eyelid cancer and the biopsy later comes back negative for cancer, you have now given that patient a condition he or she doesn’t have -- and it’s next to impossible to get that corrected with insurance companies. Plus, it could hurt the patient’s chances of getting life insurance – or could vastly elevate the cost.

What Do Signs and Symptoms Entail?

Get this straight: In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services your eye care specialist provides.

The 2019 ICD-10 guidelines stipulate that you should apply signs-and-symptoms diagnoses if:

• The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case.
• The physician makes a definitive diagnosis, but the sign or symptom is not routinely associated with that condition.
• When the patient is in a coma and requires the addition of coma scale codes to the claim.
• If the patient falls repeatedly and you need to tell the insurer about the history of falls.
• When the patient has systemic inflammatory response syndrome of non-infectious origin
• To indicate the NIH stroke scale in a patient who had an acute stroke.

Eye care highlights: Some signs and symptoms you might see in an ophthalmologist’s documentation include eye pain, blurry vision, floaters, dry eyes, lid lesions, or excessive watering.

Example: During an initial consult with a new patient complaining of eye pain, particularly when blinking, an eye care specialist suspects a diagnosis of a foreign body in the eye.

Answer: Until testing or diagnostic services confirm the foreign body diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides. In this case, that would probably be eye pain.

Will I Always Report a Definitive Dx After a Procedure?

You should report a definitive diagnosis when your physician has performed a procedure and the results confirm it. In other words, you should never assign a diagnosis until it is definitive.

Example: The ophthalmologist performs a glaucoma screening (such as G0117, Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) and confirms a diagnosis of glaucoma. In this case, you should report the glaucoma diagnosis (such as H40.11XX) as the primary diagnosis.

However, if your ophthalmologist performs a procedure and the evidence is inconclusive, you should fall back on signs and symptoms.

Can I Ever Report a ‘Rule-Out’ Dx?

You should never report “rule-out” diagnoses in the outpatient setting. “Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients,” the ICD-10-CM Guidelines indicate.

By taking this approach, you avoid labeling a patient with an unconfirmed diagnosis while still allowing for your eye care specialist’s reimbursement for services rendered, even if she cannot establish a definitive diagnosis through testing.

Watch out: The following phrases in your physician's documentation can indicate that the physician has not formally diagnosed the patient with the condition or disease:

• Probable
• R/O or rule out
• Suspected
• Likely
• Questionable
• Possible
• Still to be determined.

Example: You shouldn't claim a diagnosis of retinopathy hoping you’ll be paid if the ophthalmologist has not (or cannot) establish definitively retinopathy diagnosis, even if he notes “Rule out retinopathy” in the medical record.

Instead, you should assign codes for other documented symptoms, such as blurred vision, seeing spots, or vision loss to describe the patient’s symptoms in the absence of a retinopathy diagnosis.

Your physician’s documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the diagnostic testing outcome.

With a Definitive Dx, Are Symptoms Secondary?

Occasionally, you’ll report sign and symptoms as secondary diagnoses, even if your ophthalmologist has assigned a definitive diagnosis for a patient encounter.

When? You can report “signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis,” according to CMS transmittal AB-01-144.

Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your physician’s medical decision-making or otherwise determine how he formulates a patient’s treatment.

In fact, ICD-10 guidelines state, “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

In other words: If your ophthalmologist’s definitive diagnosis doesn’t present a complete picture of a patient’s condition, then you may assign additional signs and symptoms codes in addition to the definitive diagnosis to support your physician’s claim.

On the other hand, if your physician’s definitive diagnosis explains or supports the service he provides for the patient, you should not report signs and symptoms in addition to the definitive diagnosis, ICD-10 guidelines state.