Ophthalmology and Optometry Coding Alert

Get the 411 on what to code – and what to leave off – your claims.

Choosing the ICD-10 codes that most accurately reflect a healthcare encounter can be really complicated if you don’t understand the myriad of guidelines involved in the process. When things get tricky, having a solid understanding of these rules will help you decipher which diagnosis codes are best to assign, which is a must if you want to submit clean claims and avoid potentially catastrophic consequences for patients.

Follow along as we set the record straight on four myths related to reporting signs and symptoms.

Myth: Under No Circumstances Should You Report Symptom Codes

Reality: In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for the services your eye care specialist provides.

Consider applying signs-and-symptoms diagnoses in situations such as the following:

• The physician is unable to establish a definitive diagnosis, even after they have investigated all the facts bearing on the case.
• The provider does not specifically link a particular sign or symptom to a diagnosis.
• Additional workup of the sign/symptom is planned or necessary.
• The provider establishes a diagnosis, but the sign or symptom is not normally associated with that disease or condition.
• Certain signs/symptoms that represent important problems that the physician might wish to classify in addition to a known cause.

Eye care examples: Some signs and symptoms you might see in an ophthalmologist’s documentation include eye pain, blurry vision, floaters, dry eyes, lid lesions, excessive tearing, or headache.

For instance: A new patient presents to the office complaining of foreign body sensation in the right eye and eye pain, particularly when blinking, and the doctor suspects a diagnosis of a foreign body in the eye. Until examination and/or diagnostic testing confirms a diagnosis of an ocular foreign body, you should report the patient’s signs and symptoms to justify why the services your physician provides are medically necessary. In this case, that would be H57.8A1 (Foreign body sensation, right eye) and H57.11 (Ocular pain, right eye).

If you are reporting the symptoms rather than a definitive diagnosis, your claim will be stronger if you code everything the patient is experiencing rather than just choosing one sign or symptom. “It is appropriate to code all diagnoses that co-exist at the time of the visit that affect patient treatment or management,” says Matthew Menendez, vice president of sales and marketing with White Plume Technologies. “As always, make sure documentation supports your coding.”

Myth: You Can Code a ‘Rule-Out’ Dx on Office Visit Claims

Reality: You should never report rule-out diagnoses in the outpatient setting, which is where most ophthalmic care is provided, says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group. “Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients,” the ICD-10-CM guidelines indicate. By taking this approach, you avoid labeling a patient with an unconfirmed diagnosis.

Watch out: Mention of the following in your ophthalmologist’s documentation can indicate that they have not formally diagnosed the patient with the condition or disease:

• Possible
• Questionable
• Rule out (R/O)
• Still to be determined
• Suspected
• Probable
• Likely

For instance: It is not appropriate to use a retinopathy code on the claim, hoping you’ll be paid if the ophthalmologist has not, or cannot, definitively establish a retinopathy diagnosis, even if they note “suspected” or “probable” in the medical record.

Instead, assign codes for the patient’s documented symptoms — such as blurred vision (H53.8 (Other visual disturbances)), seeing floaters (H53.19 (Other subjective visual disturbances)), visual impairment (H54.7 (Unspecified visual loss)) — to describe what they are experiencing in the absence of a retinopathy diagnosis. Your eye care provider’s documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the diagnostic testing outcome. In such cases, you would “report pertinent systemic conditions as well, such as diabetes or hypertension,” Johnson adds.

Myth: Always Assign a Definitive Dx After a Procedure

Reality: Only after your ophthalmologist has examined the patient and performed the appropriate testing confirming a diagnosis should you report it. However, if your eye care provider’s exam and tests are inconclusive, you should rely only on the signs and symptoms to establish medical necessity for services rendered.

For example: A patient is referred by their optometrist due to complaints of frequent headaches and blurry vision. Upon exam, the ocular findings are entirely normal and there is no significant refractive error; uncorrected visual acuity is recorded at 20/20 distance and J1 near. Thus, you’d report the symptoms on your claim for reimbursement: R51.9 (Headache, unspecified) and H53.8 (Other visual disturbances) for the blurred vision.

Myth: Avoid Reporting Signs and Symptoms With a Definitive Dx

Reality: Occasionally, you’ll report signs and symptoms as secondary diagnoses, even if your provider has assigned a definitive diagnosis for a patient encounter.

When? You can report “signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis,” according to CMS transmittal AB-01-144. Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your physician’s medical decision making or otherwise determine how they formulate a patient’s management and treatment.

In fact, ICD-10 guidelines state, “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

In other words: If your ophthalmologist’s definitive diagnosis doesn’t present a complete picture of the patient’s condition, then you may assign additional codes for pertinent signs and symptoms along with the code for the confirmed diagnosis to support your physician’s claim.

On the other hand, if your physician’s diagnosis does explain or support the service provided for the patient, you should not report signs and symptoms in addition to the definitive diagnosis, ICD-10 guidelines state.