Ophthalmology and Optometry Coding Alert

See if you can zero in on the best-suited codes for each scenario.

While coding for a significant portion of ocular diagnoses is relatively straightforward, there are always a few outliers that are more challenging. Familiarizing yourself with rare conditions and those with tricky coding rules that can often cloud your code selection decisions will prevent them from stopping you in your tracks.

To help you gauge your level of expertise in coding corneal diagnoses, we’ve put together a quick quiz. Try answering the following coding scenarios before reading the solutions.

Use the Alphabetic Index To Find Fuchs’ Dystrophy

Question 1: A 52-year-old patient presents to the clinic with a chief complaint of blurry vision that started in their right eye a few months ago, although it hasn’t interfered with daily activities until the past few days. Recently, the haziness has begun to affect both eyes, which have become very sensitive to bright light. On examination, the ophthalmologist discovers bilateral corneal swelling, tiny blisters on the front surface of both corneas, and drop-like bumps on the back surface. She diagnoses the patient with Fuchs’ dystrophy. Which ICD-10 code should you report?

Solution: Fuchs’ dystrophy doesn’t have an exclusive ICD-10 code, but it falls under the general code for endothelial corneal dystrophy. Start by turning to the Alphabetic Index and looking for Dystrophy, Fuchs,’ which leads you to H18.51- (Endothelial corneal dystrophy). When you flip to the Tabular List to confirm the code (H18.513), a note under the code descriptor indicates that this code includes Fuchs’ dystrophy diagnoses.

Recognize 2 Pterygia in 1 Eye Is Dubbed ‘Double’

Question 2: A 42-year-old patient who drives a tour boat for a living comes to the office complaining of redness and irritation in their right eye, and a small bump on the conjunctiva. The patient states the pink growth has become more irritating in recent weeks. A slit lamp exam reveals two pink, fleshy growths of the conjunctiva that are spreading across onto the cornea, one in each corner of the right eye. The physician diagnoses the patient with double pterygium. Which code should you report?

Solution: Pterygium — nicknamed “surfer’s eye” because they work in the same elements that cause pterygium, sun, wind, and dusty conditions — can happen to anyone who spends a lot of time outdoors in the sun without eye protection. While you might be tempted to report a standard unspecified bilateral pterygium code (H11.003) due to the patient having two pterygia, that would be incorrect in this case. Because both pterygia are in the right eye, the appropriate code would be H11.031 (Double pterygium of right eye).

Coding tip: You don’t need to separately report the symptoms of pain and irritation since a more definitive diagnosis was ultimately discovered.

Know Where to Look for Corneal Abrasions

Question 3: A 35-year-old new patient presents urgently with an eye that is painful, tearing, light-sensitive, and red. The patient says that while playing basketball with friends, the basketball hit them in the head and likely scratched their eye. On examination, the ophthalmologist discovers that the patient suffered a corneal abrasion in the right eye. Which code(s) apply?

Solution: ICD-10 has a slew of codes specific to corneal abrasions and sports-related ocular injuries, and it can be a challenge to know them all. To report a corneal abrasion, you’ll look outside of the “H” section of ICD-10, Diseases of the Eye and Adnexa, where most eye conditions are located. Instead, you’ll flip to the “S” section, Injury, Poisoning, and Certain Other Consequences of External Causes, because an external force caused the eye injury. The appropriate code for this condition is S05.01XA (Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter).

Don’t stop there: While some payers don’t require the external causes of morbidity ICD-10 codes, you should get in the habit of using them. If you were to code the patient example above correctly and completely, in addition to the primary code (S05.01XA), you would also report the following codes:

• W21.05XA (Struck by basketball, initial encounter)
• Y92.310 (Basketball court as the place of occurrence of the external cause)
• Y93.67 (Activity, basketball)

Remember: The 7th character indicates the status of the injury and care. “A” would indicate that this is the initial visit, and the patient is under active management.