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Ophthalmology and Optometry Coding Alert

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Does Old BB-Gun Injury Have Bearing on Coding?

Published on Mon Apr 26, 2010

Question: We have a patient who came in for a routine eye exam, but reported retinal damage from a BB-gun incident six years ago. What would be the best way to code this? This is a new patient, and I do not have any old records. Montana SubscriberAnswer: Unless the BB-gun injury six years ago has something to do with why the patient is there, it may not have any bearing on your coding. The diagnosis code always depends on the reason for the visit. If the patient decided to see an optometrist because of eye pain, eye pain (379.91, Pain in or around eye) -- or whatever the optometrist found that was causing the pain -- would be the diagnosis.If the eye pain is indeed the late effect of the BB-gun  injury, you could report 906.0 (Late effect of open wound of head, neck and trunk) as a secondary diagnosis."When reporting [...]
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