Ophthalmology and Optometry Coding Alert

Question: Often, the physician will list several symptoms and signs that the patient is experiencing, along with a definitive diagnosis at the top of the note. Should we list all of those diagnosis codes on the claim?

Codify Subscriber

Answer: Occasionally, you'll report sign and symptoms as secondary diagnoses, even if your ophthalmologist 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 he formulates a patient's 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 a patient's condition, then you may assign additional signs and symptoms codes in addition to the definitive diagnosis to support your physician's claim.

On the other hand, if your eye care doctor's definitive diagnosis explains or supports the service he provides forthe patient, you should not report signs and symptoms in addition to the definitive diagnosis, ICD-10 guidelines state.