Ophthalmology and Optometry Coding Alert

Question: We had a 55-year-old patient with type 1 diabetes come in presenting with a chief complaint of blurred vision (both distance and near). The patient's primary-care physician told her she needed an eye exam. Other than the diabetes, she's in good health, but my ophthalmologist diagnosed mild non-proliferative diabetic retinopathy and mild diabetic macular edema. He ordered fundus photographs and an extended threshold fields exam. How should I report all these services? Should I start with a consultation code?

New York Subscriber

Answer: You may only report a consultation code if the primary-care physician has specifically requested your ophthalmologist's opinion, advice and recommendations for treatment. This does not seem to be true in the scenario you relate in your question. Your ophthalmologist may report an E/M code (99201-99215) depending on the service level he provided and documented or one of the ophthalmology service codes (92002-92014), again based on the services performed and documented.

Next, report 92250 (Fundus photography with interpretation and report) for the fundus photography your ophthalmologist decided to perform.

Also, code the threshold fields exam using 92083 (Visual field examination, unilateral or bilateral, with interpretation and report; extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2]).

Diagnosis roundup: There is no specific ICD-9 code for diabetic macular edema. You should report 362.01 (Background diabetic retinopathy) to cover both listed diagnoses in the chart.

You could also list a secondary diagnosis of 368.8 (Blurred vision NOS) because the patient's chief complaint was blurred vision.