Ophthalmology and Optometry Coding Alert

Question: A 72-year-old patient presented with high intraocular pressure in the right eye, a sign of glaucoma, and the doctor decided to perform a visual field (VF) examination. The results of the visual field were normal, and the doctor ruled out the possibility of glaucoma. Which diagnosis code should I link to the VF procedure?

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Answer: Because the results of the VFs were negative— they did not confirm glaucoma or any condition— you should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code, and include any additional observations from the VFs in the office notes.

In this case, the appropriate diagnosis code is H40.011 (Open angle with borderline findings, low risk, right eye). Some payers may require H40.001 (Preglaucoma, unspecified, right eye) when the diagnostic testing does not confirm glaucoma. Your best bet is to check with your local carrier to determine if billing guidelines exist.

If, however, a patient presents with signs and symptoms of glaucoma, and a VF confirms the condition, you should report the code for the confirmed diagnosis.

Example:  The doctor performs visual fields for a patient who presents with high intraocular pressure, open angle, and the VFs confirm the presence of small scotomas in the areas of the VF related to glaucoma. The diagnosis code should be linked to the appropriate glaucoma diagnosis, such as H40.10X0 (Unspecified open-angle glaucoma, stage unspecified). Scotomas in other areas may suggest another diagnosis.