Ophthalmology and Optometry Coding Alert

Question: Our providers use the superbill to select their ICD-10 codes, but we only have the most frequently-reported codes listed on there. For diagnoses that aren't on the superbill, they frequently mark an unspecified code in the EHR or they'll keep approaching the coders for advice. Is there a way around this?

Codify Subscriber

Answer: Yes. Your superbill is a good resource for general coding direction, but it can't possibly list all of the coding combinations inherent to ICD-10. The new diagnosis coding system often requires a level of specificity that goes beyond what could be listed on one piece of paper, asking about upper and lower eyelids and whether the right, left, or bilateral eyes were affected. Therefore, you should instead ensure that all of these codes are available in your electronic health record.

If your EHR isn't yet configured to help you find the right diagnosis codes for your visits, now is the time to speak with your vendor about setting up that feature. Include not only all of the available ICD-10 codes, but ask the system to prompt the doctor for more information when necessary. For instance, if the physician types in "blepharitis," the system should ask whether it's ulcerative, squamous, unspecified, etc. It should also prompt the doctor to enter the affected eye and eyelid so the coder can most accurately select a diagnosis code.

You might also try using laminated ICD-10 reference sheets available at the nursing/physician stations outside the exam rooms which can be color coded and quickly accessed to determine the most accurate ICD-10 to simply be written on the superbill and give to the patient for check-out.