Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist saw a patient with a foreign-body (FB) sensation in her left eye. She was convinced that something like an eyelash was in the eye, but the doctor found nothing there. Which diagnosis code applies?

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Answer: Proper diagnosis coding requires the most specific code to describe the findings, which, in this case, is the patient’s symptoms. Per ICD-10 guidelines, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.”

This is why it’s so important to ensure that every condition the doctor addresses is noted in the patient record. If a definitive diagnosis is not discovered, the signs and symptoms in the documentation will be what you report on your claim.

Note the novel FB codes: New for 2024 is subcategory H57.8A- (Foreign body sensation eye (ocular)), and now that Oct. 1, 2023, is in the review mirror, in cases like these, you can submit H57.8A2 (… left eye) if no underlying condition is causing the FB sensation.

Double-check for a cause: Review the patient’s chart thoroughly. If you find that the patient has dry-eye syndrome and your physician assigns that as the cause of foreign-body sensation, use an ICD-10 code to identify the type, such as H04.122 (Dry eye syndrome of left lacrimal gland) or H16.222 (Keratoconjunctivitis sicca, not specified as Sjogren’s, left eye).

If it is solely a FB complaint and the patient is in pain, but the source of the pain cannot be identified (e.g., eyelash, foreign body, abrasion), code the symptom. Consider an unspecified eye pain code, such as H57.12 (Ocular pain, left eye) or a code representing a specific injury causing the pain; for example, S05.02XA (Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial encounter).