Ophthalmology and Optometry Coding Alert

Question: We are getting denials from Medicare when we use the code 374.00 for an entropion. Should we be more specific in the code?

Nebraska Subscriber

Answer: According to the current ICD-9 manual, code 374.00 (entropion, unspecified) is considered a nonspecific code. The code is listed in the ICD-9 manual with an amber triangle indicating it is a nonspecific code.

Medicare and other payers usually pay for services or procedures based on the diagnosis code(s) that the local Medicare carrier has determined make the service reasonable and necessary. Nonspecific diagnoses can be denied by any payers for lack of medical necessity. Each payer determines which diagnosis codes demonstrate medical necessity for their payment purposes.

The most specific ICD-9 code can only be submitted for the diagnosis if it is documented in the patient medical record or operative report. Under the category 374.0 (entropion and trichiasis of eyelid), codes 374.01 (senile entropion), 374.02 (mechanical entropion), 374.03 (spastic entropion), 374.04 (cicatricial entropion) and 374.05 (trichiasis without entropion) are listed as specific codes. The most specific ICD-9 code that applies to the patient should be documented in the medical record or operative report to enhance the probability of payment. This will require you to communicate with your physician(s) regarding the available specific diagnoses, explain the payment problem, and get their support for billing by getting them to document the more specific diagnosis(es).