Optometry Coding & Billing Alert

Question: Should I report a dry eye diagnosis code based on my clinical findings or the patient's complaints?

Indiana Subscriber

Answer: You should base your code on your clinical findings.

Example: If the patient complains of dry, sandy- or gritty-feeling eyes, or a foreign-body sensation, and you see diffuse punctate staining, punctate keratopathy, epithelial defects, sterile corneal ulcers, corneal vascularization, or corneal scarring, then you may want to diagnose dry eye. Report 370.33 (Keratoconjunctivitis sicca, not specified as Sj-gren-s).

Or if a tear volume test reveals low tear volume, 375.15 (Tear film insufficiency, unspecified) may be the appropriate choice.

Depending on your findings, you may also determine that you should report 370.21 (Punctate keratitis), 370.34 (Exposure keratoconjunctivitis), or 710.2 (Sj-gren's disease).

If you don't have a definitive diagnosis, you code patient symptoms, such as 379.91 (Eye pain), 379.93 (Redness of eyes), or 375.20 (Epiphora, unspecified as to cause).

-- Answers to You Be the Expert, Reader Questions and Build a Better Business reviewed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas.