Ophthalmology and Optometry Coding Alert

Question: A 53-year-old new patient with type 1 diabetes presented to the clinic with a chief complaint of blurred vision (both distance and near) bilaterally. The patient’s primary care physician told them they needed an eye exam. Other than diabetes, the patient is in good health. My ophthalmologist ordered fundus photographs and an extended threshold fields exam and arrived at a diagnosis of mild nonproliferative diabetic retinopathy and mild diabetic macular edema. How should I report all these diagnoses and services? Should I start with a consultation code?

South Carolina Subscriber

Answer: It is only appropriate for you to 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 the case in the scenario you outlined in your question.

Your ophthalmologist may report the new patient visit with an E/M code (99202-99205 (Office or other outpatient visit...)), depending on the level of service they provided and documented, or one of the ophthalmology service codes (92002-92004 (Ophthalmological services: medical examination and evaluation …)), again based on the services performed and documented.

Next, report 92250 (Fundus photography with interpretation and report) for the fundus photographs your ophthalmologist decided to perform to document baseline retinal findings and facilitate tracking disease progression.

Also, code the extended examination of the extent of the patient’s visual field using 92083 (Visual field examination, unilateral or bilateral, with interpretation and report; extended examination …). Note the diagnoses that support coverage of diagnostic tests vary by payer. And not all payers reimburse for visual fields to assess diabetic eye disease. So, check your individual payer policies.

Diagnosis roundup: There is a specific ICD-10 code that captures all the patient’s diagnoses that you should use: E10.3213 (Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral). Note that this code requires a 7th character — 1 for right eye, 2 for left eye, 3 for bilateral, 9 for unspecified eye — to designate laterality. In this case, the patient is having issues in both eyes, so you would use “3” as the 7th character to indicate the condition is bilateral.

Coding tip: Since blurred vision is a known side effect of these conditions, you would not need to include a diagnosis code such as H53.8 (Other visual disturbances) to capture the patient’s chief complaint of blurred vision.