Ophthalmology and Optometry Coding Alert

Question: Our eye care physician documented that a patient had “childhood measles 10 years ago.” How should I document this?

Massachusetts Subscriber

Answer: In this particular situation, ICD-10 guideline IV.J tells you that you should “not code conditions that were previously treated and no longer exist.” But the guideline also goes on to tell you that “history codes (categories Z80- Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

In other words, coding in this situation is very much dependent on the reason your provider is seeing the patient. If the provider is seeing the patient for a condition unrelated to the measles, then you do not need to code for the patient’s history of measles.

However, if the provider is seeing the patient for a condition related to a sequela of childhood measles, you could possibly use a personal history code, in this case Z86.19 (Personal history of other infectious and parasitic diseases). That’s because an instructional note to parent code Z86.1- (Personal history of infectious and parasitic diseases) tells you that you can use codes in the group for “conditions classifiable to A00-B89, B99,” which includes the B05.- (Measles) codes.

Example: The patient developed encephalitis as a result of the measles, and the encephalitis resulted in optic neuritis. If your provider is treating the patient for one of those conditions, you would code the condition being treated as the primary diagnosis with Z86.19 as a secondary.