Ophthalmology and Optometry Coding Alert

Question: Our retinal doctor performed surgery for retinal detachment (67108) and said the diagnosis is “retinal detachment with occult breaks of the right eye.” Would that be coded as a single break? The op note states that no definitive retinal break was noted. What ICD-10-CM code should we report?

Idaho Subscriber

Answer: The answer depends on what’s missing from the operative report and why. If the physician said the diagnosis is retinal detachment with occult breaks in the right eye, that should be justified somewhere in the record. Perhaps it’s in the pre-op notes rather than the op report, or it’s in dictation rather than in the electronic medical record, but you should not report a “retinal detachment with breaks” diagnosis code if no breaks were noted.

If you do find documentation of retinal breaks, you must then determine how many breaks were seen because the code choice depends on it:

• H33.011 (Retinal detachment with single break, right eye)
• H33.021 (Retinal detachment with multiple breaks, right eye)

Reporting one of these codes would require that the physician documented retinal break(s), so double-check with the surgeon for confirmation.

If the operative report is accurate and no breaks were observed, report the code that aligns with the diagnosis documented. For instance, physicians will repair a retinal tear that didn’t include an actual break, necessitating a retinal tear code instead. However, depending on your op report, that may not justify reporting 67108 (Repair of retinal detachment; with vitrectomy, any method …), as a retinal tear or break is different from a retinal detachment. Verify that the procedure you coded is correct if you find an alternate diagnosis when you talk to the physician.

Bottom line: You should query the ophthalmic surgeon to find out more specifics about the actual diagnosis. Once you have that information, read through the operative note in detail to confirm that 67108 is the most accurate code for the surgery performed.