Ophthalmology and Optometry Coding Alert

Hint: Etiology may drive code choice when reporting cataracts.

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

To ensure you know how to best report diagnoses, we’ve put together a quick quiz. Read the following coding scenarios and see whether you can pinpoint the answer before reading the solutions.

Get Specific When Reporting Glare Sensitivity

Question 1: A 53-year-old patient has a chief complaint of photophobia, and the ophthalmologist documents glare sensitivity in the medical record. You report H53.8 (Other visual disturbances). Is this the most appropriate code choice?

Solution: No, you should only report H53.8 as a primary diagnosis code when the doctor doesn’t arrive at a more definitive diagnosis during the course of the visit. If you can, kick the specificity up a notch, as many carriers would see this as not medically necessary without further documentation. Instead of reporting the general code, you should bill H53.71 (Glare sensitivity) in this case, which more accurately describes this patient’s condition.

Let Direction of Deviation Drive ‘Tropia’ Dx

Question 2: A parent brings their 8-year-old child to the clinic because they’re concerned about the child’s right eye wandering upward. The provider diagnoses the patient with hypertropia. Which code should you report?

Solution: Hypertropia is a type of strabismus — misalignment of the eyes — that occurs when one eye turns upward, putting it out of alignment with the other eye. You should code this condition as vertical strabismus, which means the correct ICD-10 code, in this case, is H50.21 (Vertical strabismus, right eye).

This condition is often confused with the other “tropia” diagnoses. The key to figuring out which to choose is knowing the direction of the deviation. In esotropia, the eye turns inward; exotropia is when the eye turns outward; and cyclotropia is rotation of the eye around its anterior-posterior axis.

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

Eye the Details if Cataracts Result From Drug Use

Question 3: A 61-year-old patient, who has been on glucocorticoids for several years, complains of blurred vision. The ophthalmologist diagnoses the patient with bilateral cataracts due to long-term glucocorticoid use. Which codes apply?

Solution: When a patient’s cataracts stem from drug use, you’ll report a code from the H26.3- (Drug-induced cataract) group. Because the patient’s cataracts affect both eyes in this case, the most appropriate code is H26.33 (Drug-induced cataract, bilateral).

But don’t stop there: The ICD-10 code book indicates that you should report an additional code to reflect the adverse effect, identifying the drug. Therefore, you’ll report T38.0X5 (Adverse effect of glucocorticoids and synthetic analogues) as the secondary diagnosis code.

Consider Corneal Abrasion an Injury

Question 4: A 45-year-old new patient presents to the office with pain, redness, and tearing in their right eye. They state they mowed the lawn earlier that day and thought the eye irritation they were experiencing was just allergies, but later in the day they noticed that their vision was blurred, and they developed a headache. On examination, the physician discovers that the patient suffered a corneal abrasion in the right eye. Which ICD-10 code(s) apply?

Solution: 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 of the book (Injury, Poisoning, and Certain Other Consequences of External Causes) since an external force caused the eye injury. In this case, the appropriate code is S05.01XA (Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter).

Look for Details About the Etiology of Hypotony

Question 5: A 53-year-old patient, who recently underwent bilateral trabeculectomy to treat their glaucoma, presents with poor vision and is diagnosed with hypotony in both eyes. How can you select the right code among the many options?

Solution: “Choosing the appropriate code from the H44.4- (Hypotony of eye) category will depend on whether you know enough about the condition to select a code more specific than simply unspecified hypotony [H44.40]. It’s up to the ophthalmologist to provide enough information to code beyond this basic option,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group. You should be able to read the documentation and glean an accurate code.

The first coding options listed in the ICD-10 code book involve flat anterior chamber hypotony (H44.41-), which typically happens after surgery due to aqueous humor leaking from the eye, resulting in low intraocular pressure (IOP). Other types of hypotony involve an ocular fistula (H44.42-), which can happen due to trauma or naturally if the patient has a related condition such as high blood pressure or vascular disease. You may also see patients with hypotony due to other ocular disorders (H44.43-) or with primary hypotony (H44.44-).

Remember: Once you’ve selected the correct code range for your patient, you’ll add a 6^th character, depending on which eye is affected, such as a “1” for the right eye, “2” for the left eye, or “3” for both eyes.

Therefore, if you see a patient with bilateral hypotony due to a postsurgical aqueous humor leak, you’ll report H44.413 (Flat anterior chamber hypotony of eye, bilateral).