Ophthalmology and Optometry Coding Alert

Can you code this diabetic retinopathy scenario?

Although some diagnosis coding scenarios are extremely straightforward, the ICD-10 code set also includes a few head-scratchers, particularly when it comes to eye care conditions. But if you know a few simple tips, you can reduce the number of denials you receive due to incorrect coding, bringing cash into your practice much faster.

To identify the answers to three of the most recent questions that readers submitted to Ophthalmology and Optometry Coding Alert, we sat down with Elizabeth Cifers, MBA, MSW, CHC, CPC, of Elizabeth Cifers Consulting, LLC. Check out her advice on how to correctly code these common scenarios.

Reach the Highest Level of Specificity

Question: “Many ICD-10 codes go out to six or even seven characters, but our ophthalmologists don’t always provide an adequate amount of detail for them to code out that far,” one reader said. “For instance, in some cases the documentation will refer to the right eye, but then the physician will say he addressed the left eye, leaving us to wonder whether the left, right, or bilateral code applies. Is there a solution to this that will allow us to improve our coding accuracy in the future?”

Answer: For the scenario presented, Cifers recommends showing the discrepancy in the documentation to the physician. “Once the answer is clarified, the physician should amend the chart note with the appropriate information,” she advises. “If the physician uses a scribe, educating both the physician and scribe is essential.”

If the chart documentation does not provide the highest level of specificity to assign a diagnosis code correctly, always show the provider the options in the ICD-10-CM code book so they can see the dilemma in selecting the correct code, she says. “Many physicians have been documenting the same way since residency and fellowship and do not realize the level of specificity that ICD-10-CM requires,” Cifers says. “Education concerning the problem is key to correcting and preventing future occurrences.”

Don’t be afraid to speak up when there is a question or discrepancy in the documentation, she adds. “Unless someone informs the physician, they may not know there is an issue.”

Combination Codes May Not Require You to Use Secondary Codes

Question: “We are confused about whether secondary conditions should be reported,” an optometry coder wrote. “For instance, if a patient has diabetic retinopathy, should we also code diabetes as a secondary ICD-10 code? Or is it inherent to the diabetic retinopathy code?”

Answer: In this situation, there’s no need to report the secondary code, Cifers says. “Diabetic retinopathy is known as a ‘combination code,’” she says. “Combination codes refer to a single ICD-10-CM code that identifies either two diagnoses or a diagnosis with an associated complication or manifestation.”

Therefore, she says, only report the combination code, “as it is inclusive of the second diagnosis, complication, or manifestation,” Cifers advises.

Of course, combination codes may not exist for every combination diagnosis, so in some cases, you will have to report multiple codes when the patient has multiple conditions. However, when combination codes exist, you should always use them rather than adding additional codes in their place.

Avoid Suspected Diagnoses

Question: “Suppose a patient presents complaining of blurred vision or a scratchy feeling in the eye, but the physician ultimately doesn’t find anything wrong with them,” another subscriber asked. “Should we code the symptoms or the suspected condition?”

Answer: You shouldn’t code the suspected condition, Cifers notes. “If there is no definitive diagnosis, the signs and symptoms are the correct way to code,” she advises. “Remember first to locate the term in the Alphabetical Index, then use the Tabular list to verify the code selection, the laterality, and, if applicable, the seventh character code.”