Ophthalmology and Optometry Coding Alert

Understand what happens if no diagnosis is discovered.

In some cases, coding the diagnoses on an ophthalmology chart may be a simple task, particularly when the patient has one straightforward diagnosis that the physician clearly documents in the medical record. In other situations, however, you may have to pore over the notes and consult several sets of guidelines to find the right ICD-10-CM code for a particular claim.

To ensure that you know how to best report diagnoses, take this quick quiz and find out whether you’re able to pinpoint the right diagnosis code.

1. Understand Normal Diagnostic Results

Question 1: The ophthalmologist refers a patient to a radiologist for an orbital CT scan with a symptom of eye pain. The CT scan, when interpreted by the physician, reveals the presence of an abscess of the right upper eyelid. Both the radiologist — when reporting for the technical component of the CT scan, and the ophthalmologist — when reporting for the follow-up E/M visit for the same test, should report the diagnosis with H00.031 (Abscess of right upper eyelid). However, what should you do if the diagnostics had come out normal?

Answer 1: If the diagnostic test does not provide a definitive diagnosis or if it came out with normal results, you should code the sign or symptom that prompted the treating physician to order the study. Say, in the previous scenario, the CT scan results came back without any abnormal findings, then you would report the symptom (the eye pain) instead of H00.031.

If the diagnostic test was normal, but the referring physician records a suspected (a.k.a. probable, suspected, questionable, rule out, or working) diagnosis, you should not code the referring diagnosis. Instead, you should again report the presenting signs and symptoms. The ICD-10-CM guidelines warn, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.” For instance, suppose the physician’s notes indicated “suspected blockage of a tear duct,” but the CT scan came out normal. Again, you would report the symptom rather than the suspected condition as the reason for the test.

Keep in mind: If the patient is receiving only diagnostic services during the outpatient visit, you would list first the condition that is the main reason for the visit on the claim. This code should be your primary diagnosis. Then, code for other diagnoses (such as chronic conditions) on the following lines. For example, say a patient with glaucoma got the CT scan, and test results revealed the presence of an abscess. On your claim you should list H00.031 as your primary diagnosis and glaucoma as your secondary diagnosis.

Remember: “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” state the 2022 ICD-10-CM Official Guidelines for Coding and Reporting, which went into effect on October 1, 2021. “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present,” the guidelines note.

2. Differentiate Screening From Confirmed Diagnosis

Question 2: Your ophthalmologist diagnoses a patient with glaucoma and you report Z13.5 but the claim is rejected. What went wrong?

Answer 2: You should only report ICD-10 code Z13.5 (Encounter for screening for eye and ear disorders) on your glaucoma screening claims, meaning the claims that you submit to screen healthy patients for this condition. If your patient already has glaucoma, you will instead report the definitive diagnosis code for the exact type of glaucoma they have.

The main category of glaucoma codes is H40-H42 (Glaucoma). This category includes about 250 codes, some of which stretch to seven characters.

The seventh character represents the stage of the glaucoma, as follows:

• 1 — mild
• 2 — moderate
• 3. — severe
• 4 — indeterminate

For instance, if the patient presents with primary open-angle glaucoma of the right eye in the moderate stage, you’d report H40.1112 (Primary open-angle glaucoma, right eye, moderate stage).

3. Don’t Forget All Relevant Codes

Question 3: A 5-year-old girl falls from the jungle gym on the school playground and suffers a 2.0-cm cut on her right eyelid.

The ophthalmologist performs a simple repair and submits the claim with S01.111 as the diagnosis code, but an auditor says you didn’t code correctly. What went wrong?

Answer 3: In this case, you forgot to add the external cause code.

For the scenario presented, you should report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) linked to a primary diagnosis of S01.111 (Laceration without foreign body of right eyelid and periocular area) and a supplementary diagnosis of W09.2XXA (Fall on or from jungle gym, initial encounter).

You should use ICD-10-CM external cause codes as secondary codes when the additional information about the patient’s condition is relevant to treatment and patient care.

You should never sequence an external cause code as the first-listed or principal diagnosis, according to the ICD-10-CM Official Guidelines for Coding and Reporting.

External cause codes can tell healthcare providers treating the patient the following helpful information:

• Cause: The code can explain how the injury or health condition happened. For example: A horse struck the patient and injured the patient’s foot — W55.12XA (Struck by horse, initial encounter).
• Intent: The code can explain whether the injury or health condition was unintentional, accidental, or intentional. For example: The patient intentionally jumped in front of a vehicle and injured his ankle — X81.0XXA (Intentional self-harm by jumping or lying in front of motor vehicle, initial encounter).
• Place: The code can explain the place where the event occurred. For example: The patient broke her ankle while playing soccer on a soccer field — Y92.322 (Soccer field as the place of occurrence of the external cause).
• Activity: The code can explain the patient’s activity at the time of the event. For example: The patient was boogie boarding when he broke his toe — Y93.18 (Activity, surfing, windsurfing and boogie boarding).
• Status: The code can explain the patient’s status. For example: Y99.8 (Other external cause status).