Ophthalmology and Optometry Coding Alert

Question: A 33-year-old patient presented to our office with hypotony. Which is the right diagnosis code for this?

New Jersey Subscriber

Answer: Choosing the appropriate ICD-10 code from the H44.4x (Hypotony of eye) category will depend on your ability to determine whether the patient has unspecified hypotony (H44.40) or whether you know more about the condition. It’s up the ophthalmologist to provide enough information to code beyond this basic unspecified option, and you should be able to read the documentation and glean an accurate code.

The first coding option listed in the ICD-10 code book involves flat anterior chamber hypotony (H44.41x), which typically happens after a surgery due to aqueous humor leaking from the eye and reducing the pressure. Other types of hypotony involve an ocular fistula (H44.42x), which can happen due to trauma or naturally if the patient has a related condition such as high blood pressure or vascular disease. You may also see patients with hypotony due to other eye issues (H44.43x) or with primary hypotony (H44.44x).

Once you’ve selected the correct code range for your patient, you’ll also add a sixth digit, depending on which eye is affected, such as a “1” for the right eye, “2” for the left eye, or “3” for both eyes.

Therefore, if you see a patient with bilateral hypotony due to an ocular fistula, you’ll report H44.423.