Ophthalmology and Optometry Coding Alert

Question: There are times when a patient says something to ancillary staff, but there’s no mention of the issue in the ophthalmologist’s documentation. If a patient tells the medical assistant who rooms them that they are experiencing excessive tearing in both eyes, but the physician does not include epiphora in their note, can we as coders denote H04.213 as one of the diagnosis codes to capture the excessive lacrimation that the patient reports is occurring bilaterally?

Georgia Subscriber

Answer: You can code based on what a patient says, but only if that information is documented by someone qualified to make a diagnosis. Medical assistants (MAs) are not considered qualified healthcare professionals (QHPs), and thus anything they document should not be coded without first checking with the provider.

It is important that you remember who is allowed to document in the patient’s record and what they can, and cannot, report. ICD-10 guideline I.B.14 tells you, “Code assignment is based on the documentation by the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing a patient’s diagnosis).”

The guideline goes on to mention a few exceptions to this rule, which include the codes for:

• Body mass index (BMI)
• Coma scale
• NIH stroke scale (NIHSS)
• Social determinants of health (SDoH)
• Laterality
• Blood alcohol level
• Underimmunization status
• Depth of non-pressure chronic ulcers
• Pressure ulcer stage

For example, a dietitian might document BMI, or an emergency medical technician (EMT) might document the coma scale score, but the patient’s provider must document the associated diagnosis (such as obesity, overweight, acute stroke, etc.) for you to be able to report it. You can include the codes for BMI, coma scale, NIHSS, blood alcohol level, SDoH, and underimmunization status, but only as a secondary diagnosis.

Additionally, guideline I.C.21.c.17 explains that “Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.”

Remember: QHPs are distinct from clinical staff. A clinical staff member is an employee who works under the supervision of a physician or other QHP to perform, or assist in the performance of, a specified professional service as allowed by law, regulation, and facility policy, but who does not individually report that professional service.

Possible QHPs — depending on state scope of practice, licensing, and payer guidelines — are:

• Nurse practitioner (NP)
• Certified nurse specialist (CNS)
• Physician assistant (PA)
• Certified nurse midwife (CNM)
• Certified registered nurse anesthetist (CRNA)
• Clinical social worker (CSW)
• Physical therapist (PT)

In your scenario, even though MAs are qualified to provide a wide range of basic care — such as phlebotomy, taking vital signs, dressing wounds, updating records, and even educating patients on a variety of health issues — they cannot document many of the above. Most important, however, they cannot document any clinical diagnoses such as any H04.213 (Epiphora due to excess lacrimation, bilateral lacrimal glands).Only a physician or QHP can document such a diagnosis.