Optometry Coding & Billing Alert

Question: A patient referred to our office had high intraocular pressure, and the optometrist performed a visual field (VF) examination to determine a diagnosis of glaucoma. The results of the VF were normal. Which diagnosis code should I use?

Indiana Subscriber

Answer: Because the result of the visual field was negative, code for the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code (92083, Visual field examination, unilateral or bilateral, with interpretation and report; extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2]) and include any additional observations from visual fields in his office notes. These notes should be in the interpretation and report required for any visual field test.

In this case, the appropriate diagnosis code is 365.01 (Borderline glaucoma [glaucoma suspect]; open angle with borderline findings).