Ophthalmology and Optometry Coding Alert

Choose the appropriate diagnosis after reading the case.

Although most eye care practices see patients with retinal disorders every day, that doesn't mean each diagnosis code is the same. In fact, for every three retinal disorder patients you see, you may report three different ICD-10 code combinations, depending on the subtleties between the patients' conditions.

Check out the following three scenarios and determine how you would code these cases.

Retinal Artery Occlusion

Scenario: A patient with high blood pressure who has presented in the past for dry eyes but has never had a retinal problem comes to the practice complaining of a sudden vision loss in the left eye but has no pain. Upon examination, the physician sees a retinal artery occlusion due to a thrombus. The physician uses eyedrops to decrease eye pressure, and the occlusion is dislodged.

Coding Solution: In this case, the retinal artery occlusion is considered "transient" because it is not permanent. You know this since the occlusion dislodged and moved out of the artery. Therefore, you should look to the H34.0 (Transient retinal artery occlusion) section of the ICD-10 manual for this condition. Since the condition was in the left eye, the accurate code is H34.02 (...Left eye).

Retinopathy of Prematurity

Scenario: The ophthalmologist is called to evaluate a baby in the neonatal intensive care unit who is on oxygen therapy due to premature lung development. The patient is not believed to have oxygen toxicity but upon examination using an ophthalmoscope, the physician determines that the retinal blood vessels have not grown appropriately and diagnoses her with stage two retinopathy of prematurity in both eyes.

Coding Solution: Because the patient's retinopathy of prematurity is in stage two, you'll look to H35.13 (Retinopathy of prematurity, stage 2), and since the condition affects both eyes, the appropriate code is H35.133 (...bilateral).

Central Serous Retinopathy

Scenario: A new patient presents to the office with blurred vision in his right eye, and he says he can see a small spot right in his field of vision. The ophthalmologist administers dilation drops and examines the retina using OCT and fluorescein angiography, which show fluid leakage. The physician diagnoses the patient with central serous retinopathy. He advises her to return in two weeks to determine if the condition resolves and to monitor progress.

Coding Solution: To report central serious retinopathy, you'll look to the H35.71 (Central serous chorioretinopathy) series, since "chorioretinopathy" is simply another word for the same condition. Since the diagnosis impacts the patient's right eye, you'll report H35.711 (...right eye).