Ophthalmology and Optometry Coding Alert

Question: Our retinal doctor performed a surgery for a retinal detachment (67108) and said the diagnosis code should be “retinal detachment with occult breaks of the right eye.” Would that be coded as a single break? In the op note it states that no definitive retinal break was noted. How should we report the ICD-10 code?

Indiana Subscriber

Answer: The answer depends on what’s missing from the operative report, and why. If the physician said the diagnosis is retinal detachment with occult breaks of the right eye, then that should be justified somewhere in the record. Perhaps it’s in the pre-operative notes rather than the op report, or it’s in dictation rather than in the electronic medical record, but you should not report the retinal detachment with breaks diagnosis code if no breaks were noted.

If you do find documentation of the breaks, you must then determine how many breaks were observed, because the code choice depends on it. Depending on whether the physician addressed a single break or several, the coding options would be:

• H33.011 (Retinal detachment with single break, right eye)
• H33.021 (Retinal detachment with multiple breaks, right eye)

Reporting one of these codes would require that the physician has documentation of the retinal break(s), so double-check with the surgeon on confirmation of that.

If the operative report is accurate and no breaks were observed, then you must report an appropriate code based on which diagnosis was determined. For instance, some physicians will repair a retinal tear that didn’t include an actual break, necessitating a retinal tear code instead. However, depending on the operative report, that may not justify reporting 67108 (Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique), so double check that the correct procedure was coded if you find alternate diagnoses when you talk to the physician.

In short, you should query the surgeon to find out more specifics about the actual diagnosis, and once you have that information, read through the operative note in detail to confirm that 67108 is the most accurate code for the surgery performed.