Ophthalmology and Optometry Coding Alert

Question: A 16-year-old boy presented with a scratchy sensation from a foreign body in his left eye. The ophthalmologist examined him and found sawdust resulting from cutting firewood. No serious damage or laceration of the cornea resulted. Lacking a serious outcome, which diagnosis code should I use?
      
Virginia Subscriber

Answer: To select the proper diagnosis code, you need to refer to the documented patient complaint if the ophthalmologist did not make a definitive diagnosis.
 
In this case, the physician identified the source of the problem - a foreign body- so you should report 930.0 (Corneal foreign body). 
 
If the ophthalmologist had not located a foreign body, you would have had to report codes for the patient's symptoms, for example, 379.91 (Pain in or around eye) or 379.93 (Redness or discharge of eye).