Ophthalmology and Optometry Coding Alert

Question: A Medicare-only patient with diabetes came in for his annual exam. There was no diabetic retinopathy or any other disease other than refractive error. It is my understanding that Medicare will deny the diagnosis code 250.00. Is there any other option to code for his annual diabetic exam so Medicare will pay?

California Subscriber

Answer: Most Medicare carriers recognize 250.00 (diabetes mellitus without mention of complication) and 250.01 (diabetes with ketoacidosis) as valid, reasonable and necessary diagnoses for an examination of the visual system. Patients do not have to have an ophthalmic manifestation of the diabetes. In the past, many Medicare carriers denied these services as though they were for routine exams or exams with no chief complaint.

The key to correct billing and coding for a diabetic eye exam is in the patient history. Medicare ICD-9 guidelines state that documentation should describe a patients condition, including diagnosis, symptoms, problems or reason for the encounter. Codes 001.0 through 999.0 describe the reason for the encounter.

The reason for this patients exam is diabetes, so document this diagnosis in the patient history, and the chief complaint would be, Patient is here for diabetic eye exam. Remind your technicians of the importance of the patient interview. When a patient has diabetes, he or she may have blurry vision. The technician must ask this question and include it in the chief complaint. If, during the course of the exam, the physician finds another diagnosis for the patient, that becomes the primary diagnosis on the claim form, and 250.00 becomes the secondary diagnosis. If the diabetes is type II adult-onset, noninsulin-dependent diabetes, the correct code for no ophthalmic involvement is 250.00. If it is type I juvenile, insulin dependent with no ophthalmic involvement, the code is 250.01.