Ophthalmology and Optometry Coding Alert

Learn the details that lead to maximum code specificity.

Retinal conditions run the gamut from inflammation and vascular pathologies to detachment and breaks. Due to their prevalence, most eye care practices see patients with such problems every day, requiring you to understand how to differentiate the retinal disorder ICD-10 codes from one another and report them properly.

Fortunately, six tips can help you nail down the right retinal diagnosis code every time.

Tip 1: Recognize Which Retina Codes Require Laterality

For example, the H35.8- (Other specified retinal disorders) codes, such as H35.81 (Retinal edema), have no laterality. However, when retina codes do require it, your code must include a 5th (e.g., H33.4- (Traction detachment of retina)) or 6th (e.g., H34.23- (Retinal artery branch occlusion)) character to indicate the eyes affected: “1” (right), “2” (left), or “3” (both).

Code H35.35- (Cystoid macular degeneration) also requires the additional character: H35.351 (… right eye), H35.352 (… left eye), and H35.353 (… bilateral). For some codes, you may even go a step further — H59.03- (Cystoid macular edema following cataract surgery) requires laterality. With these codes, you may submit a “status-post condition” Z code, as well.

Likewise, the codes for posterior vitreous detachment (H43.81-) and floaters (H43.39-) have laterality, but the code for visual halos, H53.19 (Other subjective visual disturbances), does not.

Tip 2: Wait for Confirmation Before Coding Retinitis Pigmentosa

Patients who present with suspected retinitis pigmentosa typically complain of visual disturbances (H53.8), low vision (H54.5-), blindness (H54.-), night blindness (H53.60), peripheral vision loss (H53.459), and/or other low vision complaints. If the ophthalmologist has yet to make a definitive diagnosis of pigmentary retinal dystrophy, however, you should only code these signs and symptoms.

“Do not code probable, suspected, questionable, or rule out conditions until they are confirmed,” notes Joy Woodke, COE, OCS, OCSR, director of coding and reimbursement for the American Academy of Ophthalmology. Once the eye care specialist diagnoses a patient with retinitis pigmentosa, then you’ll report H35.52 (Pigmentary retinal dystrophy).

Tip 3: Let These Details Guide Retinal Break Code Choice

When submitting a diagnosis code for retinal break, you must scour the documentation for specifics such as the type of break, presence or absence of detachment, and laterality. These details will help you determine the best code to describe the patient’s condition. For example:

• H33.00- (Unspecified retinal detachment with retinal break)
• H33.01 (Retinal detachment with single break)
• H33.02- (Retinal detachment with multiple breaks)
• H33.03- (Retinal detachment with giant retinal tear)
• H33.04- (Retinal detachment with retinal dialysis)
• H33.2- (Serous retinal detachment)
• H33.3- (Retinal breaks without detachment)
  • H33.30- (Unspecified retinal break)
  • H33.31- (Horseshoe tear of retina without detachment)
  • H33.32- (Round hole of retina without detachment)
  • H33.33- (Multiple defects of retina without detachment)
  • H33.4- (Traction detachment of retina)

Exception: Defying the greater specificity trend, there are no ICD-10 codes for old retinal detachments. For example, instead of ICD-9 code 361.06 (Old retinal detachment, partial), you’ll report ICD-10 code H33.8 (Other retinal detachments) and in lieu of 361.07 (Old retinal detach total or subtotal), you’ll use H33.05- (Total retinal detachment).

Tip 4: Know Other Conditions That Call for Maximum Specificity

The devil is in the details when reporting retinopathy of prematurity (ROP), as well. In addition to the stage of disease, you must also specify the eye(s) affected. Thus, when the diagnosis is ROP stage 0 (H35.11-), if you only report H35.11, it will result in a claim denial, as a 6th character to indicate laterality is required.

Case scenario: The ophthalmologist is called to evaluate a premature baby on oxygen therapy in the neonatal intensive care unit. The patient is not believed to have oxygen toxicity, but upon ophthalmoscopic examination, the physician determines that the retinal blood vessels have not grown appropriately and diagnoses the neonate with stage 2 ROP in both eyes.

Coding Solution: Because the patient’s ROP is in stage 2, you’ll look to H35.13- (Retinopathy of prematurity, stage 2), and since the condition affects both eyes, the correct code is H35.133 (... bilateral).

Specificity is also important when reporting inflammation of the inner cavity of the eye, as there are numerous codes for the various types of endophthalmitis: gonococcal (A54.39), purulent (H44.00-), chronic vitreous abscess (H44.02-), parasitic (H44.12-), and bleb associated (H59.4-), many of which require you to indicate the eye(s) affected

Tip 5: Recognize Central Serous Retinopathy = Chorioretinopathy

Central serous retinopathy (CSR), also known as central serous chorioretinopathy (CSC), is a condition in which fluid accumulates under the retina, causing a serous (fluid-filled) detachment and vision loss. Recognizing that ICD-10 considers chorioretinopathy and CSR interchangeable will enable you to land on the right code.

Case scenario: A new patient presents with blurred vision in their right eye and a small spot right in their field of vision. The ophthalmologist examines the retina using optical coherence tomography (OCT) and fluorescein angiography, which show fluid leakage. They diagnose the patient with CSR and tell them to return in two weeks to monitor progress and determine if the condition has resolved.

Coding solution: To report CSR, you’ll look to the H35.71- (Central serous chorioretinopathy) series, and since the diagnosis impacts the patient’s right eye, you’ll report H35.711 (… right eye).

Tip 6: Mind ICD-10’s Instructional Notes

Remember, Excludes1 notes flag diagnosis codes that can’t be reported for the same eye at the same time. An example of this is mutually exclusive scarring: the listing for H31.01- (Macula scars of posterior pole …) has an Excludes1 note indicating that if you report H31.01-, you can’t also report H59.81- (Chorioretinal scars after surgery for detachment) for the same eye. Likewise, H33.3- (Retinal breaks without detachment) has an Excludes1 note indicating that you can’t also report H59.81- or H35.4- (Peripheral retinal degeneration without break) on the same day for the same eye.

“ICD-10 also indicates the order in which some codes should be reported,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group. When coding H32 (Chorioretinal disorders in diseases classified elsewhere), you must mind not only the Excludes1 note for chorioretinitis in acquired toxoplasmosis (B58.01) and tuberculosis (A18.53) but also the instructions telling you to first code the underlying disease — for example, congenital toxoplasmosis (P37.1), histoplasmosis (B39.-), or leprosy (A30.-).