Revenue Cycle Management in the Age of ICD-10: A Primer for Ophthalmology

Ophthalmology icd 10 codes for neovascular glaucoma and more!Continuing our series on ICD-10 basics we are offering high-level primers to illustrate the differences on specific documentation requirements for various specialties. We will also give some samples of how ICD-9-CM codes common for those specialties compare to ICD-10-CM codes. Again, much of the material in these speciality-specific blog posts is based on guidelines and material published by CMS in its Road to 10 Series. There is a lot of questionable information and advice out there and we want to help improve the consistency and reduce the uncertainty by going to the source of regulations. We will summarize and consolidate to enhance readability and brevity. The application of ICD-10 documentation requirements and the common ICD-10 codes for Ophthalmology is the focus of this post. In ICD-10-CM, there are three main categories of changes:

  • Definition Changes
  • Terminology differences
  • Increased specificity

A significant change for ophthalmology is a chapter (chapter 7) devoted solely to diseases of the eye and adnexa. In ICD-9, the sense organs (eye and ear) were included in the chapter on nervous conditions. Now, each has its own chapter, although codes in both chapters start with the letter H.

Codes Eye Conditions
H00-H05 Disorders of the eyelid, lacrimal system, and orbit
H10-H11 Disorders of the conjunctiva
H15-H22 Disorders of the sclera, cornea, iris, and ciliary body
H25-H28 Disorders of the lens
H30-H36 Disorders of the choroid and retina
H40-H42 Glaucoma
H43-H44 Disorders of the vitreous body and globe
H46-H47 Disorders of optic nerve and visual pathways
H49-H52 Disorders of ocular muscles, binocular movement, accommodation, and refraction
H53-H54 Visual disturbances and blindness
H55-H57 Other disorders of the eye and adnexa
H59 Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified

In Ophthalmology, many conditions are listed as right eye, left eye, bilateral, or unspecified. Many conditions of the eyelids are further differentiated as affecting the right upper, left upper, right lower, or left lower eyelid. For glaucoma, a seventh character denotes the stage of the disease. Furthermore, in conformance with ICD-10 convention, postprocedural complications of eye surgeries are located in this chapter. The right, left and bilateral eye conventions are:

  • .**1=right eye
  • .**2=left eye
  • .**3=bilateral (both eyes)
  • .**9=unspecified eye[not recommended]

ICD-10 Eyelid Codes follow the HCPCSE codes (1-4) There are now seven options for each eyelid:

  • .**1=RUL (Right Upper Lid)
  • .**2=RLL (Right Lower Lid)
  • .**3=Right Eye (unspecified lid) [not recommended]
  • .**4=LUL (Left Upper Lid)
  • .**5=LLL (Left Lower Lid)
  • .**6=Left Eye (unspecified lid) [not recommended]
  • .**9=Unspecified eye; unspecified lid  [not recommended]

Example: Cataracts ICD-9 CM

H366.16 Nuclear Sclerosis

ICD-10 CM

H25.1 Age-related nuclear cataracts
H25.10 Age-related nuclear cataract, unspecified eye
H25.11 Age-related nuclear cataract, right eye
H25.12 Age-related nuclear cataract, left eye
H25.13 Age-related nuclear cataract, bilateral

Eye Injuries and Complications

Injuries to the eye are coded in chapter 19. Unlike the ICD-9 code book, the injury chapter in ICD-10 is not organized by type of injury. Rather, it is organized anatomically, and then by type of injury. For example, a laceration without foreign body of the left eyelid and periocular area is code with diagnosis code S01.112. Injury codes in ICD-10 require a seventh character to indicate the number of the encounter that the patient is being seen for that injury (eg, initial encounter vs subsequent or follow-up encounter). The first patient encounter for the injury would be coded as S01.112A. A follow-up encounter uses the same code but changes the seventh character extender, so the code for a subsequent encounter would be S01.112D. ICD-10 includes intraoperative and postprocedural complications in the chapter-related system, another change from ICD-9. In the eye chapter, these complications are in the H59 block, which has 57 diagnosis codes for disorders of the eye following cataract surgery, intraoperative hemorrhage and hematoma of the eye and adnexa, accidental puncture and laceration of the eye and adnexa, postprocedural hemorrhage, inflammation (infection) of postprocedural bleb, chorioretinal scars after surgery for detachment, and other intraoperative or postoperative complications not elsewhere classified. Most of these codes include laterality. An example is H59.111: "Intraoperative hemorrhage and hematoma of the right eye and adnexa complicating an ophthalmic procedure."

Coding Glaucoma

The glaucoma family of codes runs from H40-H42. Laterality is one of the main difference that distinguish ICD-10 from ICD-9. While not all of the glaucoma diagnosis codes require it, many do. Laterality is indicated in the sixth digit. The other difference between ICD-10 and ICD-9 is the introduction of glaucoma severity staging. Optional at present and coded separately, staging will be mandatory under ICD-10. Stage is denoted in the seventh, or last digit, of the code. Staging is based on a combination of optic nerve condition and visual fields. Like in ICD-9 coding, the choices for staging are 0,1,2,3 and 4.

  • 1 mild: No visual field loss on white-on-white standard perimetry, but the optic nerve looks glaucomatous
  • 2 moderate: Optic neuropathy consistent with glaucoma, plus visual field loss in one hemifield on,and not within 5 degrees of fixation
  • 3 severe: A glaucomatous optic disk plus visual field loss in two hemifields. Alternately, if the visual field loss is limited to one hemifield, it involves the central 5 degrees
  • 4 indeterminate: Either the doctor cannot determine the nature of the visual loss, or the patient has not been tested yet, or the patient performed very poorly on the visual field test so the physician cannot rely on the test results to arrive at a diagnosis

The addition of laterality and the requirement of staging means that the number of codes used for glaucoma have increased exponentially. Some glaucoma diagnostic codes that had single codes under ICD-9 are no longer in the glaucoma-specific codes in ICD-10. Neovascular glaucoma is an example. There is no glaucoma with vascular disorder code (365.63 in ICD-9). Instead, code glaucoma with ocular disorder and add whatever the ocular disorder is such as central retinal vein occlusion or proliferative diabetic retinopathy. Those codes are found in other sections of ICD-10, not in Chapter 7. Finally, not all codes will have a sixth digit for laterality. An example would be primary open-angle glaucoma - coded as H40.11 - the sixth digit is missing. In this situation, an "x" should be placed in the sixth digit as a placeholder with the seventh digit used for glaucoma stage. So Open angle glaucoma, mild stage would be H40.10X1.

Diabetic Retinopathy: From Two Codes to One

In ICD-9-CM, if a patient has diabetic retinopathy or has retinopathy due to diabetes, the diabetic code (category 250) must be sequenced as the principal diagnosis followed by the code for the specific type of retinopathy as a secondary diagnosis. In ICD-10, only one code is necessary to code for ophthalmic complications of diabetes. That code will not be found in Chapter 7, however but Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-89) which includes Diabetes, malnutrition and obesity conditions. Example: ICD-9-CM

250.52 DM II Controlled
362.02 Diabetic retinopathy: proliferative diabetic retinopathy

ICD-10-CM

E11.359 Type 2 diabetes with proliferative diabetic retinopathy without macular edema

Routine Examination of the Eyes

This is coded in ICD-9-CM as V72.0.39, identifying it only as an examination without disclosing the findings of the exam as normal/abnormal. In ICD-10-CM, "V" codes or codes used for general health services when circumstances other than a disease or injury necessitated the encounter - including a screening or routine exam. In ICD-10-CM the "V" is changed to a "Z." In ICD-10-CM, exam findings must be specified along with the "Z" code So in the case of a routine eye exam without complaint, in ICD-10-CM, the code would be Z01. The final diagnosis code would then also have to include the findings from one of the following possibilities:

Z01.0 Encounter for examination of the eyes and vision
Z01.00 Encounter for examination of the eyes and vision without abnormal findings
Z01.01 Encounter for examination of the eyes and vision with abnormal findings

Comparison of ICD-9-CM and ICD-10-CM Codes for Ophthalmology

Cornea Abrasion ICD-9-CM

918.1 Cornea Abrasion

ICD-10-CM

S05.01 Injury of conjunctiva and corneal abrasion without foreign body, right eye
S05.01XA Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter
S05.01XD Injury of conjunctiva and corneal abrasion without foreign body, right eye, subsequent encounter
S05.01XS Injury of conjunctiva and corneal abrasion without foreign body, right eye, sequela
S05.02 Injury of conjunctiva and corneal abrasion without foreign body, left eye
S05.02XA Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial encounter
S05.02XD Injury of conjunctiva and corneal abrasion without foreign body, left eye, subsequent encounter
S05.02XS Injury of conjunctiva and corneal abrasion without foreign body, left eye, sequela

Squamous Blepharitis ICD-9-CM

373.02 Blepharitis

ICD-10-CM

H01.0 Blepharitis
H01.02 Squamous blepharitis
H01.021 Squamous blepharitis, right upper eyelid
H01.022 Squamous blepharitis, right lower eyelid
H01.023 Squamous blepharitis, right eye, unspecified eyelid
H01.024 Squamous blepharitis, left upper eyelid
H01.025 Squamous blepharitis, left lower eyelid
H01.026 Squamous blepharitis, left eye, unspecified eyelid
H.01.029 Squamous blepharitis, unspecified eye, unspecified eyelid

Horseshoe Tear of Retina Without Detachment ICD-9-CM

361.30 Retinal defect, unspecified
361.32 Horseshoe tear of retina without detachment

ICD-10-CM

H33.3 Retinal breaks without detachment
H33.31 Horseshoe tear of retina without detachment
H33.311 Horseshoe tear of retina without detachment, right eye
H33.312 Horseshoe tear of retina without detachment, left eye
H33.313 Horseshoe tear of retina without detachment, bilateral/both eyes
H33.319 Horseshoe tear of retina without detachment, unspecified

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