Ophthalmology and Optometry Coding Alert

Question: A patient referred to our office had high intraocular pressure, and the ophthalmologist performed a visual field (VF) examination to determine a diagnosis of glaucoma. The results of the VF were normal. Which diagnosis code should I use, since glaucoma was eliminated as a possibility?
      
Indiana Subscriber

Answer: Because the result of the visual field was  negative, code for the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code (92081, Visual field examination, unilateral or bilateral, with interpretation and report; limited examination [e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent]) and include any additional observations from visual fields in his office notes.
 
In this case, the appropriate diagnosis code is 365.0x (Borderline glaucoma [glaucoma suspect]).