Ophthalmology and Optometry Coding Alert

This quick quiz will help you determine whether you can assign the right diagnosis codes.

Coding an eye care note can be simple, involving routine vision testing codes, or complex, with a variety of coexisting conditions to report. To determine whether you’ve got the know-how to find the right ICD-10 codes, read through the following story and fill in the blanks with the appropriate diagnoses for the described conditions. Then see below to compare your responses to the correct codes.

Code This Note:

My mother suffered from higher pressures in her eyes, eventually resulting in capsular glaucoma with pseudoexfoliation of the lens (1. ___). When I was young, she was found to have a neoplasm on her cornea, but fortunately it was found to be benign (2. ___).

Several years later, she was diagnosed with cancer of her eyelid (3. ___). I know she was worried about the outcome, but she was thankful for the continued treatment including an encounter for chemotherapy (4. ___).

My maternal great aunt had Type 2 diabetes which led to retinopathy and macular edema (5. ___).

On my father’s side of the family, two aunts and an uncle were diagnosed with cortical age-related cataracts in both eyes (6. ___).

I am presenting today for an eye exam, but I also have other issues going on, (7. ___) such as dry eyes (8. ___), which the doctor diagnosed as dry eye syndrome. My previous doctor thought it was blepharitis (9.___) but he later determined that I didn’t meet the clinical criteria for that diagnosis.

ICD-10 QUIZ ANSWERS

Now that you’ve reviewed our sample note above, check out these coding quiz answers to see how you fared.

1. This glaucoma diagnosis would be reported with H40.1432 (Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage) because the patient refers to both eyes. If, however, the condition was only present in one eye, the code would be different depending on the affected eye.

2. The benign neoplasm of the cornea would be reported with D31.10 (Benign neoplasm of unspecified cornea).

3. To report the eyelid cancer, you’ll submit C44.101 (Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus).

4. You’ll turn to the “Z” codes here, reporting Z51.11 (Encounter for antineoplastic chemotherapy).

5. Here you’ll report E11.311 (Type 2 diabetes with unspecified diabetic retinopathy; with macular edema) to describe the diabetic retinopathy with macular edema.

6. For the bilateral cortical age-related cataracts, you’ll report H25.013 (Cortical age-related cataract, bilateral).

7. You’ll report Z01.01 (Encounter for examination of eyes and vision with abnormal findings) to represent the eye exam. The “abnormal findings” code applies due to the information that follows this question.

8. The code for the dry eye syndrome would be H04.12 (Dry eye syndrome).

9. The code for blepharitis would be H01.00 (Unspecified blepharitis).