Ophthalmology and Optometry Coding Alert

Question: We submitted a claim for 99204 and 92250 to Medicare. The diagnosis code for both was 250.50. Medicare continues to deny this claim, but I don't know why. The denial says, "missing/incomplete/invalid diagnosis or condition."

Ohio Subscriber

Answer: You may need an additional ICD-9 code to identify the specific ophthalmic problem the patient presents with.

Code 250.50 (Diabetes with ophthalmic manifestations; type II or unspecified type, not stated as uncontrolled) is the correct code for type II diabetes with ophthalmic manifestations, but ICD-9 rules require you to use a second diagnosis code to say what, exactly, the ophthalmic manifestations are. Fundus photography must have a specific diagnosis of what, exactly, is being photographed.

Link the E/M code (for example, 99204, Office or other outpatient visit for the evaluation and management of a new patient ...) and 92250 (Fundus photography with interpretation and report) to the ophthalmic manifestation -- such as macular edema (362.07), glaucoma (365.44) or retinopathy (362.01-362.07) -- as a secondary diagnosis.

Be sure to check with your carrier, though. It is possible that it may want just the manifestation code, not the diabetes code.