Ophthalmology and Optometry Coding Alert

Question: Can diagnosis code 379.31 (aphakia) be used for CPT 92020 (gonioscopy)?

Florida Subscriber

Answer: The medical reason for performing a service should be reported when submitting the claim to the payer. So, if the reason for performing the gonioscopy is that the patient is aphakic, that diagnosis code must be submitted. Whether or not the payer will pay the claim is another matter. Medicare carriers and many other payers use edits to help process claims through an automated procedure.

This means that your carrier will have created a list of ICD-9 codes that they feel substantiate the medical necessity requirement for paying for specific services. If aphakia is on that list, then the claim system will process the claim for payment. If it is not, you will receive a denial based on the lack of medical necessity. It will then be up to you to send the claim into review or even appeal to substantiate the medical necessity and request that the claim be paid.

Note: Aphakia is an unusual diagnosis to support gonioscopy and is therefore less likely to be on edit lists of ICD-9 codes. It might be a good idea to check with the physician to find out if there is another, more appropriate diagnosis that would apply.