Ophthalmology and Optometry Coding Alert

Question: Should I report a dry eye diagnosis code based on the ophthalmologist's clinical findings or the patient's complaints?

Indiana Subscriber

Answer: You should base your code on the ophthalmologist's clinical findings.

Example: If the patient complains of dry, sandyor gritty-feeling eyes, or a foreign-body sensation, and the ophthalmologist sees diffuse punctate staining, punctate keratopathy, epithelial defects, sterile corneal ulcers, corneal vascularization, or corneal scarring, then the ophthalmologist may want to diagnose dry eye.

Report 370.33 (Keratoconjunctivitis sicca, not specified as Sjögren's).

Or if a tear volume test reveals low tear volume, 375.15 (Tear film insufficiency, unspecified) may be the appropriate choice.

Depending on the findings, you may also determine that you should report 370.21 (Punctate keratitis), 370.34 (Exposure keratoconjunctivitis), or 710.2 (Sjögren's disease). If there is no definitive diagnosis, you code the patient's symptoms, such as 379.91 (Eye pain), 379.93 (Redness of eyes), or 375.20 (Epiphora, unspecified as to cause).