Ophthalmology and Optometry Coding Alert

Question: Our pediatric ophthalmologist was recently called to the ER to consult on a potential case of shaken-baby syndrome. He documented multiple subdural hemorrhages, mostly bilateral, and detachments. His observations led him to believe that the retinal damage was a result of shaking or abuse. Should I use a diagnosis code for the retinal damage or the suspected SBS?

Maine Subscriber

Answer: For coders, determining when documentation by an ophthalmologist concretely establishes "underlying cause" can sometimes be a diagnosis-coding nightmare.

When you have a definitive diagnosis for an eye condition, which is why your ophthalmologist is treating the patient, that diagnosis should be used. In the example you presented, your physician will report the retinal conditions, and the attending physician will report the diagnoses of the suspected condition of shaken-baby syndrome or other physician findings that he or she documented upon examination of the patient.