Ophthalmology and Optometry Coding Alert

Question: I’m trying to code a hospital consult and am struggling with the medical decision making (MDM). The CC is eye discharge. In the assessment, the physician noted preseptal cellulitis OS and bacterial conjunctivitis OU OS > OD; no signs of orbital cellulitis at this time. The plan was to start Doxy 100mg BID PO and polymyxin/ bacitracin ointment TID OU and have the patient follow up in a week for resolution of symptoms and double vision.

For problem complexity, would these be considered “self-limited or minor” or “acute, uncomplicated” diagnoses?

Mississippi Subscriber

Answer: In this scenario, you should classify the conjunctivitis as an acute, uncomplicated problem. However, it would be reasonable to classify the preseptal cellulitis as an undiagnosed new problem with an uncertain prognosis. This would be appropriate because cases of preseptal cellulitis occasionally do not respond to certain treatments as expected, hence the characterization of “uncertain prognosis.”

Therefore, in this case, you could use the preseptal cellulitis and prescription drug management to code this as a level 4 evaluation and management (E/M) visit.