Outpatient Facility Coding Alert

Question: The provider suspected glaucoma in a patient with high intraocular pressure in the right eye. He performed a visual field (VF) examination to assess the patient for glaucoma. However, as the results of the visual field were normal, the provider ruled out the possibility of glaucoma. How do we code this scenario?

Maine Subscriber

Answer: As the result of the VF examination was negative, and the provider could not make a confirmed diagnosis of Glaucoma, you should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code, and include any additional observations from the VFs in the office notes.

In this case, the appropriate diagnosis code is H40.011 (Open angle with borderline findings, low risk, right eye). Some payers may require H40.001 (Preglaucoma, unspecified, right eye) when the diagnostic testing doesnot confirm glaucoma. Your best bet is to check with your local carrier to determine if billing guidelinesexist.

If, however, a patient presents with signs and symptoms of glaucoma, and a VF confirms the condition, you should report the code for the confirmed diagnosis.

Example: The doctor performs a visual field exam for a patient who presents with high intraocular pressure, open angle, and the VFs confirm the presence of small scotomas in the areas of the VF related to glaucoma. The diagnosis code should be linked to the appropriate glaucoma diagnosis, such as H40.10X0 (Unspecified open-angle glaucoma, stage unspecified).

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