Ophthalmology and Optometry Coding Alert

All eye care practices are probably aware by now that you’ll be selecting your office and outpatient E/M codes based on either medical decision making (MDM) or time spent with the patient as of January 1, 2021. One of the best ways you can bolster your MDM documentation is to accurately assign the right diagnosis codes to your claim. That way, payers will see exactly why the physician did what they did during the visit and what conditions they addressed.

To ensure that you know how to code some of the most commonly seen eye care diagnoses, we’ve put together a quick quiz. Determine whether you know how to code these scenarios before you review the answers.

Can You Code a Failed Vision Screening?

Question 1: Suppose a patient presents to your eye care practice after failing a school vision screening. The optometrist notes no issues with the patient’s vision and determines that the patient has excellent eye health, with no abnormalities. Which diagnosis code applies?

Answer 1: In this situation, you’ll turn to the Z01.0 (Encounter for examination of eyes and vision) category, where you’ll find fairly new codes to report that describe the eye care physician’s encounter with the patient following a failed vision screening.

For the case described, you’ll report Z01.020 (Encounter for examination of eyes and vision following failed vision screening without abnormal findings). This six-character code not only tells the insurer that you saw the patient as a follow-up to a prior failed vision screening, but it may also justify a screening if you already performed one on the same patient within the prior year. The code would tell the payer exactly why you performed it again.

Are Signs and Symptoms Preferred?

Question 2: Your ophthalmologist sees a 67-year-old patient with a foreign-body sensation in her eye. She is convinced that something like an eyelash is in the eye, but the ophthalmologist finds nothing there. Which diagnosis code applies?

Answer 2: In this case, you’ll report the signs and symptoms. Although many physicians feel the need to provide a definitive diagnosis when submitting a claim, there are many circumstances in which the symptom the patient presented with is the only thing they can find. Proper diagnosis coding requires you to code the complaint that put the patient into your chair, not necessarily what the ophthalmologist ultimately found.

This is why it’s so important to ensure that every condition the doctor addresses is noted in the patient record. “The reality is to document every diagnosis they’re treating on that visit,” advises Deena Wojtkowski, CPC, CEMC, CCP, vice president of client services with ebix, Inc. If a definitive diagnosis is not discovered, the signs and symptoms in the documentation will be what you report on your claim.

Do this: Review the patient’s chart thoroughly. If you find that the patient has dry-eye syndrome, for example, that is a possible cause of foreign-body sensation. In that case, you would use an ICD-10 diagnosis code such as:

• H04.121 (Dry eye syndrome of right lacrimal gland)
• H04.122 (... of left lacrimal gland)
• H04.123 (... of bilateral lacrimal glands)
• H04.129 (... of unspecified lacrimal gland)
• H16.221 (Keratoconjunctivitis sicca, not specified as Sjögren’s, right eye)
• H16.222 (... left eye)
• H16.223 (... bilateral)
• H16.229 (... unspecified eye)

If it is a foreign-body complaint, chances are the patient is in some kind of pain, and if the pain cannot be attributed to something specific such as an eyelash, for example, you have the option of using an unspecified eye pain code, such as H57.1x (Ocular pain) or a code representing a specific result of the pain.

For example, if the foreign-body sensation resulted in inflammation, you can report S05.00XA-S05.02XA (Injury of conjunctiva and corneal abrasion without foreign body …).

Determine How Many Codes Are Necessary for Diabetic Retinopathy

Question 3: You see a patient with diabetic retinopathy. In addition to the ICD-10 code for this condition, do you also have to use another diagnosis code to represent the ophthalmic manifestation?

Answer 3: No, not unless the ophthalmic manifestation is not already covered in the “Diabetes with Ophthalmic Manifestations” ICD-10 codes. Many ICD-10 codes in this category describe both the underlying condition (diabetes) and the ophthalmic manifestation (such as, macular edema). The E11.3 (Type 2 diabetes mellitus with ophthalmic complications) range of codes specifies type II diabetes mellitus, with specific codes detailing the type and severity of ophthalmic complication:

• E11.311 (Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema)
• E11.319 (... without macular edema)
• E11.321 (Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema)
• E11.329 (... without macular edema)
• E11.331 (Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema)
• E11.339 (... without macular edema)
• E11.341 (Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema)
• E11.349 (... without macular edema)
• E11.351 (Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema)
• E11.359 (... without macular edema)
• E11.36 (Type 2 diabetes mellitus with diabetic cataract)
• E11.39 (Type 2 diabetes mellitus with other diabetic ophthalmic complication)

The E10.3 (Type 1 diabetes mellitus with ophthalmic complications) series is similarly broken down with specific ophthalmic manifestations.

However: Not all ophthalmic manifestations are covered in the E10.3 and E11.3 series. For example, E10.39 (Type 1 diabetes mellitus with other diabetic ophthalmic complication) contains an instruction to “use additional code to identify manifestation, such as: diabetic glaucoma (H40-H42).” Therefore, always read the notations that are listed following the specific diagnosis codes in the ICD-10 listing to know whether you should be using additional codes.