Ophthalmology and Optometry Coding Alert

Question: We had a patient present with high intraocular pressure, a sign of glaucoma, and the ophthalmologist decided to perform a visual field (VF) examination. The results of the visual field were normal, and the doctor ruled out the possibility of glaucoma. Which diagnosis code should I link to the VF procedure?Minnesota SubscriberAnswer: Because the results of the VFs were negative -- they did not confirm glaucoma or any condition -- you should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code, and include any additional observations from the VFs in the office notes.In this case, the appropriate diagnosis code is 365.01 (Borderline glaucoma [glaucoma suspect]; open angle with borderline intraocular pressure or cupping of optic disks). Some payers require 365.00 (Preglaucoma, unspecified) when the diagnostic testing does not confirm glaucoma. Your best bet is to check with your local carrier to determine [...]