Ophthalmology and Optometry Coding Alert

Question: I have a report for an ophthalmology visit with a 70-year-old patient who has age-related macular degeneration. The ophthalmologist performed optical coherence tomography (OCT) of the patient’s retinas in both eyes to evaluate the retinal fluid thickness. After reviewing the images and data, the physician diagnosed the patient with bilateral nonexudative age-related macular degeneration in the early dry stage.

What codes should I report for the encounter?

Minnesota Subscriber

Answer: Use 92134 (Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; retina) to report the procedure to evaluate the patient’s eyes. The provider uses the OCT imaging to view and evaluate the patient’s retina in each eye. Code 92134 features “unilateral or bilateral” in the code descriptor, which means you’ll report the code regardless of whether the ophthalmologist evaluated one or both eyes.

Next, you’ll open your ICD-10-CM code book to locate the appropriate diagnosis codes. Nonexudative age-related macular degeneration codes are listed under the H35.31- (Nonexudative age-related macular degeneration) subcategory. Here you need to consider two factors to complete the code for the condition:

• Laterality: Append the correct 6^th character to indicate which side of the body is affected.
• Staging: Use an appropriate 7^th character listed in the code book to specify the macular degeneration advancement.

In your situation, you’ll use 6^th character 3 to indicate the condition applies to both eyes, and then 1 as the 7^th character to identify that the patient’s macular degeneration is in the early dry stage. Your final ICD-10-CM code will be H35.3131 (Nonexudative age-related macular degeneration, bilateral, early dry stage) for the documented diagnosis.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC