Ophthalmology and Optometry Coding Alert

ICD-9 codes can make or break the acceptance of a claim. Coding a patient visit for the sole purpose of obtaining payment is asking for trouble, however, particularly in a post-payment review. When is the use of a covered ICD-9 code legitimate, and when may a patient be financially responsible for payment? Pay careful attention to the Medicare rules for diagnosis codes in the following examples.


1. How do we code for patients with resolving conditions? You may think you dont need a medical diagnosis code for a visit from a patient whose condition is resolved, but in the following scenario youll see that you do.

A Medicare beneficiary calls complaining that her right eye is very light-sensitive and the vision seems a little cloudy. You ask the patient to come in the same day for an evaluation. During the conversation with the patient, you discover that she was struck in the right eye by something during a gardening activity the night before. Examination reveals an anterior chamber reaction consistent with traumatic iridocyclitis (364.00). You begin the patient on prednisolone and ask her to return in two to three days. The diagnosis is 364.04 (secondary iridocyclitis, noninfectious).

The same patient returns three days later. She has been faithful with her drops, and her symptoms are considerably better. The anterior chamber reaction is less. You counsel the patient to taper her prednisolone and ask her to return in seven to 10 days. Your chart notes state secondary iridocyclitis resolving. The diagnosis on the fee slip is still 364.04. The iridocyclitis is less severe but still present.

The same patient returns nine days later. She has tapered her drop regimen as directed and is symptom-free. On examination you see no anterior chamber reaction. You ask her to remain off all drops and tell her to return as needed should she have any additional problems. Your chart note says, iridocyclitis resolved.

Do you need a medical diagnosis code when billing this follow-up visit? Remember, the purpose of the ICD-9 code is to explain why the patient is being seen, says Duran. In this case, the physician recommended the patient return to evaluate the secondary iridocyclitis, so 364.04 is the correct diagnosis code for the follow-up visit. Medicare considers a visit to be medically necessary when the patient is seen for a patient complaint of a sign and/or symptom, for a known condition or because the physician recommended a return, says Lise Roberts, vice president of Health Care Compliance Strategies, a coding and compliance consulting firm based in Jericho, N.Y. In the case of a patient presenting with complaint of a sign and/or symptom, notes Duran, if the physician diagnoses a specific medical condition, you should use that diagnosis code instead of the symptom code.

Medicare covers services that are medically necessary relating to the reason for the visit, agrees Roberts. The reason for the last visit was to ascertain that the problem had completely resolved, so the diagnosis is still 364.04. If, however, the patient returned at a later date for another problem or just to have her eyes examined, 364.04 would not be an appropriate code, says Roberts.


2. How do I code for patients with chronic conditions? A common problem for ophthalmology practices is for Medicare beneficiaries to present to your office for a routine reason such as wanting a change in glasses or an eye check-up. The problem is that Medicare does not cover routine care. The history is paramount in establishing coverage for the exam.

In this example, a Medicare beneficiary was seen six months ago, and you found she had a mild 20/30 cataract in each eye. You ask her to return in six months to check the progress of the cataracts. When she returns, she indicates no noticeable change in her vision. Your examination reveals cataracts not much different from the last visit. Is this a covered encounter? Yes, because your plan from the prior visit states follow-up in six months for a cataract check and the history for todays visit states return for cataract check. Use diagnosis code 366.12 (incipient cataract). Following a chronic disease is medically appropriate.

Medicare covers reasonable and necessary services on the basis of whether there were patient-reported signs, symptoms or known conditions such as glaucoma treated for the past five years, says Roberts. Services are also considered reasonable and necessary when there is a doctor-recommended recall for a known condition, even though the patient may not be having any new problems.


3. What about coding for a patient who doesnt have ocular disease? A Medicare beneficiary presents to your office with a complaint of a sudden, but temporary, reduction in vision. You carefully examine the patient. The media are clear, the retina is attached and healthy, and the eyes look normal. The patients complaint is what brought him in and therefore its justifiable to use that complaint as the diagnosis 368.12 (transient visual loss).

Another problematic area for diagnosis codes is rule-outs. For example, a rheumatologist refers a patient to you who has rheumatoid arthritis and takes Plaquenil. The rheumatologist is concerned about secondary maculopathy. You carefully examine the patients eyes, paying particular attention to the maculae, but you find no pathological condition. Do not use maculopathy as the diagnosis. Instead, use V58.69 (long-term [current] use of other medications; high risk medication) and 714.0 (rheumatoid arthritis) as the underlying disease.

Note: Check your Medicare bulletins for local carrier instructions on coding this scenario, Roberts recommends. Although most carriers follow the above coding protocol, some require you to list a different V code first.