Ophthalmology and Optometry Coding Alert

Question: Is it important that I use the E codes? Insurers keep rejecting claims that contain the codes.


California Subscriber
Answer: Yes, you should continue to submit claims with E codes (E800-E999)--but never as the primary diagnosis code. Instead, use the E code as a secondary code to provide additional information. Although the codes aren't payment codes, they explain the "environmental events, circumstances and conditions" that caused the injury, states the ICD-9-CM 2006 manual.

Correct coding requires you to report this added information. E codes are part of the ICD-9 system, which instructs you to code an encounter to the highest specificity possible.

Agencies also use this supplemental information for statistical purposes. E codes help public-health officials plan prevention programs, and indicate, with diagnosis codes, a classification system for injuries.

If an insurer, such as California Blue Cross Blue Shield, routinely rejects claims containing E codes, you'll have to do some extra work to obtain payment--submit a paper claim, rather than an electronic claim, and include chart notes.

Coding example: A 5-year-old girl falls from the monkey bars on the school playground and suffers a 2.0-cm cut on her eyebrow. The ophthalmologist performs a simple repair.

You should report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) linked to a primary diagnosis of 873.42 (Other open wound of head; face, without mention of complication; forehead) and a supplementary diagnosis of E884.0 (Other fall from one level to another; fall from playground equipment).