CODING Q&A

Applying ICD-10 to Retina Practice

SUZANNE L. CORCORAN, COE • PAUL M. LARSON, MBA, MMSc, COMT, COE, CPC, CPMA

This month, we are going to take a look at some retinal case studies and how to apply ICD-10 diagnosis codes to them. The answers to the cases also include some helpful search hints.

CASE 1 – RETINAL DETACHMENT

CC: Very poor vision OD – Patient notices some new flashing lights, OD

Hx: Status post retinal detachment repair 6 weeks ago with silicone oil

Test: Binocular indirect ophthalmoscopy 360° with scleral depression, OD

Dx: Recurrent retinal detachment with proliferative vitreoretinopathy

Plan: Vitrectomy, membrane peel, RD repair

What ICD-10 code(s) should be used H33.41 (PVR with traction detachment of retina, right eye)

In this case, the code has laterality and is specific to the condition found in the chart note’s Impression and Plan. Symptoms are not coded because causation is clearly noted; code signs and symptoms only when you are unable to reach a definitive diagnosis. Note: The old surgery and the presence of oil are not relevant to today’s decision to return to surgery, so they are not coded.

CASE 2 – POSTERIOR VITREOUS DETACHMENT (PVD)

CC: Flashes and floaters OD; postop cataract/IOL surgery OU 6 weeks

Hx: Pseudophakia OU

Test: Refraction: BCVA 20/20, J1 OU

Dx1: Posterior vitreous detachment, OD without RD or tear

Dx2: Pseudophakia OU

Plan: Educate on signs, symptoms of RD and tears

What ICD-10 code(s) should be used There are two valid diagnoses: H43.811 (Vitreous degeneration, right eye) and Z96.1 (Presence of intraocular lens; pseudophakia).

There is laterality for the first, but not the second, diagnosis. For most payers at this time, the second diagnosis is not required on the claim; we include it for the sake of completeness.

CASE 3 – RHEGMATOGENOUS RETINAL DETACHMENT

CC: Shadow in peripheral vision, left eye, 4:00 position, 1 day

Hx: LASIK surgery 7 months ago (-8.00 D OU)

Test: Binocular indirect ophthalmoscopy with scleral depression reveals RD OS

Dx: Recent, partial rhegmatogenous retinal detachment, single defect, macula on, OS

Plan: RD repair today

What ICD-10 code(s) should be used There are two pertinent diagnosis codes: H33.012 (RD, single defect, left eye) and Z98.89 (Other specified post-procedural state).

The first code has laterality, but the second does not. Z98.89 describes the post-LASIK status in this example; depending on the payer, the second code may not be required on the claim.

CASE 4 – SECONDARY IRITIS FROM SARCOIDOSIS

CC: Sudden pain, tearing OS x 1 day; very light sensitive

Hx: Sarcoidosis x 4 years

Dx1: Sarcoidosis

Dx2: Iritis secondary to sarcoidosis

Plan: Rx prednisolone acetate 1% Q2H. Recheck 3 days.

What ICD-10 code(s) should be used? D86.83 (Sarcoid iridocyclitis)

This is a “combination code” in ICD-10. There is no laterality. While you might also consider H20.0 (iridocyclitis) as an additional diagnosis, it has an “Excludes 1” note, meaning the two codes are regarded as mutually exclusive in ICD-10; therefore, only one of these codes should appear on the claim. When considering two possible diagnoses, remember to check each for instructions; either or both codes might have an “Excludes 1” note. In this case, H20.0 excludes D86.83, so you may not code both; we choose D86.83 because it is the more specific code in this case.

CASE 5 – INTRAOCULAR FOREIGN BODY

CC: Pain, loss of vision; sent by ER to evaluate and treat eye injury, right eye

Hx: Injured OD this morning while hammering nails at workbench

Dx1: Intraocular metallic/magnetic foreign body

Dx2: Corneal laceration with prolapse of intraocular tissue

Plan: Surgery today: 1) vitrectomy, 2) FB removal, 3) repair corneal laceration, 4) reposit tissue

What ICD-10 code(s) should be used There are three pertinent diagnosis codes to describe this situation: S05.51xA (Penetrating wound with foreign body, right eyeball), S05.21xA (Ocular laceration with prolapse or loss of intraocular tissue, right eye), and W27.0xA (Contact with workbench tool).

First, code the conditions (penetrating wound and laceration with prolapse) and then the cause of the trauma (contact with workbench tool). All three codes end in the seventh character “A” since the patient is new and because there is active treatment by the ophthalmologist. We note Medicare has published that Chapter 20 codes (external cause codes starting with V, W, X, and Y) are not necessary on claims; other payers might or might not want them.

CASE 6 – CMV RETINITIS AND HIV/AIDS

CC: Blurry vision x 1 week, OD>OS

Hx: HIV/AIDS positive; prior treatment for CMV retinitis

Test: Fundus photography reveals necrotizing retinitis

Dx1: Cytomegalovirus disease, ophthalmic

Dx2: Disseminated retinitis OD>OS

Dx3: HIV/AIDS

Plan: Antiviral agents, coordinate care with immunologist, recheck in 1 week

What ICD-10 code(s) should be used There are three required diagnoses: B20 (HIV/AIDS), B25.8 (Cytomegaloviral disease, ophthalmic), and H30.133 (Disseminated retinitis, OU).

The order of the diagnoses is important. B20 is a valid code with only three characters; the Chapter 1 Guidelines instruct that it is primary in this situation. Instructions also note to include other diagnoses as additional if present and not otherwise excluded. So, although the retinitis may seem primary, other instructions force it into the third position. In this case, all three diagnoses are necessary.

CASE 7 – CHOROIDAL MELANOMA

CC: Loss of vision in OS; referred by Dr. Optometrist for evaluation

Hx: Large intraocular dark mass OS, patient reports reduced vision x 3 mo

Test: A- & B-scan OS, fluorescein angiography OS, order blood tests

Dx: Choroidal melanoma OS

Plan: Systemic workup. Consider enucleation.

What ICD-10 code(s) should be used? C69.32 (Malignant neoplasm of left choroid)

This code can be found in two steps by using the Neoplasm Table in the alphabetic index, searching for “choroid,” and then selecting the proper column (Malignant Primary). This leads you to C69.3. Remember that you should never code directly from the Neoplasm Table; the final code is selected by going to C69.3 in the tabular file and choosing the proper laterality based on the chart notes.

CASE 8 – RETINOBLASTOMA

Operative procedure: Destruction of localized retinal lesion by photocoagulation, left eye. Exam under anesthesia, right eye

Dx: Malignant neoplasm of eye, retina – bilateral retinoblastoma

What ICD-10 code(s) should be used? There are two diagnoses required: C69.21 (Malignant neoplasm of the right retina) and C69.22 (Malignant neoplasm of the left retina).

There is no bilateral code, so you must code each eye even though they have the same disease. RP