Ophthalmology and Optometry Coding Alert

Question: A patient presented to the office for an exam and the ophthalmologist diagnosed her with an entropion of the left upper eyelid. The physician did not specify the type of entropion, but the patient has suffered from mechanical entropion in the past. Should we report the code for mechanical entropion again?

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Answer: No. Unless the physician specifically indicates in the notes that the encounter was for mechanical entropion, you should not report that code. When in doubt, you can always ask the ophthalmologist for more detail, and if he confirms and documents that the visit was for that condition, you can report the corresponding code (H02.024, Mechanical entropion of left upper eyelid).

If you don't have a way of querying the physician about the condition and the notes don't reveal any more details about the patient's entropion, you should report H02.004 (Unspecified entropion of left upper eyelid). This tells the payer that the patient has an entropion and it also indicates the location, but falls short of specifying the entropion type.