Ophthalmology and Optometry Coding Alert

Question: Is it important that I use the “External cause” codes in ICD-10? Insurers keep rejecting claims that contain the codes.

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Answer: Yes, you should continue to submit claims with these codes, which can be found in the V, W, X, and Y sections of the ICD-10 manual, but never as the primary diagnosis code. Instead, use the external cause code as a secondary code to provide additional information. Although the codes aren’t payment codes, they explain “how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military),” according to the ICD-10 manual.

Correct coding requires you to report this added information. These codes are part of the ICD-10 system, which instructs you to code an encounter to the highest specificity possible.

Coding example:  A five-year-old girl falls from the jungle gym on the school playground and suffers a 2.0-cm cut on her right eyelid. The ophthalmologist performs a simple repair.

You should report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) linked to a primary diagnosis of S01.111 (Laceration without foreign body of right eyelid and periocular area) and a supplementary diagnosis of W09.2XXA (Fall on or from jungle gym, initial encounter).