Ophthalmology and Optometry Coding Alert

The spring allergy snap will be here soon. Be prepared to treat and code eye irritations to recoup all your deserved reimbursement with this advice from the field.

For your claims to be processed successfully, you must report the most specific diagnosis code available for your patient's eye irritation. Most patients you see with eye irritations will have one of three major conditions:

1. Blepharitis (373.0x): This is an inflammation of the eyelids, particularly at the lid margins, typically associated with a low-grade bacterial infection or a generalized skin condition, according to www.allaboutvision.com.

Blepharitis occurs in two forms: anterior and posterior blepharitis. The anterior type affects the outside front of the eyelid where the eyelashes are attached. The two most common causes are scalp dandruff and bacteria. Posterior blepharitis affects the inner eyelid and is caused by problems with the oil (meibomian) glands in the eyelid. Two skin disorders are the cause: acne rosacea and scalp dandruff, relates the All About Vision Web site.

Tip: Seventy percent of dry eye patients also have blepharitis. So don't overlook coding for both conditions if both are present. A complete diagnostic picture will help the payer understand the medical necessity of the treatments chosen, which in turn will facilitate getting your claims paid.

2. Dry eye (375.15): This is caused by decreased production of fluids from tear glands, which destabilizes the natural tear film, allowing it to break down rapidly and create dry spots on the eye surface, according to www.mayoclinic.com. An imbalance in the substances that make up the tear film also causes dry eyes. Treatment of dry eye aims to restore a more normal tear film to minimize dryness, blurred vision, and discomfort.

3. Conjunctivitis (372.xx): Otherwise referred to as allergic disease or "pink eye," this ailment is characterized by redness and inflammation of the membranes (conjunctiva) covering the whites of the eyes and the membranes on the inner part of the eyelids, according to www.medicinenet.com. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents, as well as to underlying diseases within the body. Viral and bacterial forms of conjunctivitis are common in childhood, but they can occur in people of any age, relates the Medicine Net Web site.

Consider Primary Reason for Visit Experts advise: If the primary diagnosis is a routine check-up and blepharitis or conjunctivitis is a secondary finding, the practice should still code for a routine visit.

Example: A new patient comes in for a routine eye exam. The ophthalmologist performs a comprehensive exam and discovers tear film insufficiency. Report 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits), and link it to V72.0 (Examination of eyes and vision). As a secondary diagnosis, report the dry eye with 375.15 (Tear film insufficiency, unspecified). If the primary reason for a new or subsequent visit is medical, then the office crosswalks to the minor evaluation and management (E/M) codes -- 99201-99215 -- leaving the 92000 codes behind. The E/M codes require specific levels of history, examination, and medical decision making, notes Raequell Duran, CPC, president of Practice Solutions, a coding, compliance, and reimbursement consulting firm based in Santa Barbara, Calif. The 920xx codes do not have those requirements, she explains.

Important: This means that you may need to focus on taking a more complete history to support submitting codes in the 99201-99215 range. You must also document the extent of your examination and the complexity of your medical decision making.

Example: A patient with chronic blepharitis (373.00, Blepharitis, unspecified) comes in due to a recent foreignbody sensation. During the history intake, the patient mentions a recurring headache (784.0, Headache). The patient had an unremarkable comprehensive exam four months ago, and you don't think it's necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye (930.0, Corneal foreign body). Refraction indicates a significant increase in hyperopia (367.0, Hypermetropia), which may explain the headache.

You can report an E/M code -- as long as you meet the documentation guidelines for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined with the E/M codes that are not as specific with the eye codes. Many carriers will look for an E/M code if there is a medical diagnosis.

Keep in mind that an ophthalmologist may report either the eye codes (92002"92014) or the E/M codes (99201"99215) for any encounter as they see appropriate.

There are no hard and fast rules and only strong suggestions to report the eye codes vs. E/M codes, experts say.