Ophthalmology and Optometry Coding Alert

"Question: What is the best way to code for Plaquenil toxicity observation: first, if the patient was referred by the family doctor for a baseline exam prior to the start of treatment; second, if the patient returns six months after the start of treatment to assess ocular changes; and, third, if the patient returns six months later and shows adverse ocular changes?

Marie Stamper, CMM
Ward Eye Center, FL

Answer: Plaquenil (hydroxychloroquine) is a drug used to treat malaria, lupus erythematous, ormost commonlyrheumatoid arthritis. A potential side effect of the drug is ocular change that can affect the patients vision; the patient should be monitored regularly to check for these changes. You should use an evaluation and management services (E/M) office or other outpatient visit code (99201-99215) for the procedure code. For the diagnosis code, use V58.69 (long-term [current] use; of other medications) for the primary diagnosis, and then the diagnosis code which applies to the systemic condition for which the patient is taking Plaquenil (e.g., 714.2, other rheumatoid arthritis with visceral systemic involvement). For the baseline exam done before the patient is taking Plaquenil, use an E/M code with the arthritis as the primary diagnosis. And if you do see adverse changes during a follow-up check for Plaquenil toxicity (in most parts of the country you should still use V58.69 as the primary diagnosis), but use the changes as a secondary diagnosis, as well as the arthritis (or whatever the reason is for the drug to be taken), a few Medicare carriers will want the ocular change as the primary diagnosis and the V58.69 code as secondary. If you are submitting electronically, it is likely best to use the ocular change diagnosis since you can only enter one diagnosis in the field. You can always list the V58.69 code in the note or comment field. In general, you should always list as primary the diagnosis code which most clearly indicates the medical necessity for an ophthalmologist to see the patient.
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