By Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I AHIMA-approved ICD-10-CM/PCS trainer
Loss of sight, or even the reduction of vision, impacts patients and their families both socially and economically. In the United States, an estimated 14 million people aged 12 and over have some type of visual impairment, and approximately 61 million adults are believed to be at high risk for acute vision loss.
The human skull contains two recesses, each known as an orbit, or eye socket. Within this bony conical orbit sits the contents of the eye and its ancillary parts (i.e., muscles, nerves, blood vessels). The optical system is the most complex organ system of the human body and is subject to specific disease processes.
Glaucoma
Glaucoma is a malfunction of the fluid pressure within the eye. The pressure rises to a level that can cause damage to the optic disc and nerve. Treatment can successfully prevent blindness or any vision loss. Glaucoma is essentially categorized as either:
- Open angle: a slowly developing, chronic condition that typically has no signs or symptoms until very advanced
- Closed angle: a painful condition with a sudden onset and rapidly progressing vision loss
The treating physician should include in the documented diagnosis of glaucoma the current stage of development of this condition:
- Mild stage, evidence of changes in the aqueous outflow system of the eye
- Moderate stage, elevated intraocular pressure
- Severe stage, atrophy of the optic nerve and loss of the visual field
For unusual circumstances, ICD-10-CM includes an option to report indeterminate stage. Some codes for glaucoma diagnoses require coders to report the stage with the seventh character.
Codes for reporting glaucoma include:
- H40.032, anatomical narrow angle, left eye
- H40.2221, chronic angle-closure glaucoma, left eye
The codes specify laterality and ICD-10-CM includes codes for bilateral glaucoma. Coders can only use the bilateral code if the diagnosis for both eyes is exactly the same.
For example, if a physician documents the patient has mild chronic angle-closure glaucoma, coders would report H40.2231 (chronic angle-closure glaucoma, bilateral, mild stage). However, if the physician documented mild stage in the right eye and moderate stage in the left eye, coders would report two codes:
- H40.2222, chronic angle-closure glaucoma, left eye, moderate stage
- H40.2211, chronic angle-closure glaucoma, right eye, mild stage
When eye drops, oral medication, or laser treatments have failed to control the patient’s glaucoma, the physician may perform a trabeculectomy. In this procedure, the physician makes an incision into the trabecular tissue of the eye to drain the excess fluid that has accumulated. In some cases, the physician may insert a drainage tube.
Coders will report these procedures using ICD-10-PCS root operation Drainage (Taking or letting out fluids and/or gases from a body part). The ICD-10-PCS codes specify laterality as well as whether a device is used. Examples include:
- 089SXZZ, Drainage of conjunctiva, right, external approach
- 089TX0Z, Drainage of conjunctiva, left, inserting drainage device
Diabetic retinopathy
Patients diagnosed with diabetes mellitus are at risk for ophthalmic manifestations of their abnormal glucose levels. The most common is diabetic retinopathy, a condition that causes damage to the tiny blood vessels inside the retina. Diabetic retinopathy progresses through four stages of development:
- Mild nonproliferative retinopathy (microaneurysms)
- Moderate nonproliferative retinopathy (blockage in some retinal vessels)
- Severe nonproliferative retinopathy (more vessels are blocked, depriving the retina from blood supply)
- Proliferative retinopathy (new weak and fragile blood vessels form to bypass blocked vessel, hemorrhage into the vitreous, tractional retinal detachment)
When treatment is implemented in the early stages, vision loss can be reduced. Therefore, individuals with diabetes mellitus are encouraged to get regular eye exams. Diabetic retinopathy is one of the leading causes of blindness in U.S. adults, affecting more than 4 million Americans.
The ICD-10-CM codes for diabetes are combination codes that include complications of diabetes. Examples for diabetes with diabetic retinopathy include:
- E10.331, Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
- E11.36, Type 2 diabetes mellitus with diabetic cataract
In cases where the bleeding in the eye is severe, the physician may perform a vitrectomy, the surgical removal of vitreous gel from the center of the eye. Coders will determine the root operation based on the intent of the procedure. Examples include:
- 08B43ZX, Biopsy (diagnostic excision) of the vitreous, right eye, percutaneous approach
- 08B53ZZ, Excision of the vitreous, left eye, percutaneous approach
Hypertensive retinopathy
Patients with hypertension (high blood pressure) can develop damage to the retina because of the unusually high pressure of the blood traveling through the vessels. This condition is known as hypertensive retinopathy. The higher the pressure and the longer this condition has been ongoing, the more severely the retina may be harmed.
The ICD-10-CM codes for hypertensive retinopathy specify laterality and include:
- H35.031, hypertensive retinopathy, right eye
- H35.032, hypertensive retinopathy, left eye
The only treatment available currently for hypertensive retinopathy is to reduce and control the patient’s hypertension.
Foreign matter in the eye
Tiny specks of dirt, gravel, debris, etc., can fly into a patient’s eyes and may need to be surgically removed.
ICD-10-CM includes a variety of codes to describe different injuries to the eye caused by foreign bodies, including:
- S05.51XA, penetrating wound with foreign body of right eyeball, initial encounter
- T15.02XA, foreign body in cornea, left eye, initial encounter
These codes require a seventh character to indicate the episode of care. When the foreign body is difficult to remove, the physician may admit the patient to the hospital for a surgical extirpation. Extirpation is the root operative term used by ICD-10-PCS to report the “taking or cutting out of solid matter from a body part.” Examples of the codes include:
- 08C0XZZ, Extirpation from the right eye, external approach
- 08C9XZZ, Extirpation from the cornea, left eye, external approach
The ICD-10-PCS table includes additional body part characters for the right and left sclera, conjunctiva, and cornea.
Epiretinal Implants
Modern technology is making headway to help some of those who are blind, or suffer with low vision, improve their quality of life, particularly for those patients who have lost their vision due to degenerative eye conditions (e.g., retinitis pigmentosa or macular degeneration). Epiretinal implants have four major components: a camera chip, a visual processor, a transponder, and the implant itself.
They can be used to treat the following conditions, among others:
- H35.52, pigmentary retinal dystrophy
- H35.30, unspecified macular degeneration
The surgical procedure to insert the prosthesis is reported with ICD-10-PCS codes:
- 08H005Z, Insertion of epiretinal visual prosthesis in right eye, open approach
- 08H105Z, Insertion of epiretinal visual prosthesis in left eye, open approach
If the surgeon performs the procedure bilaterally, report both codes.
Nasolacrimal duct stenosis
Nasolacrimal duct (NLD) stenosis is a condition that may be congenital or acquired. A patient may acquire an NLD stenosis as a result of:
- Granulomatous disease, such as sarcoidosis
- Sinus condition
- Formation of dacryoliths (calculus in the lacrimal duct or sac)
Physician documentation should include the specification of congenital or acquired.
Examples of codes for NLD stenosis include:
- H04.553, acquired stenosis of bilateral nasolacrimal ducts
- Q10.5, congenital stenosis and stricture of lacrimal duct
A dacryocystorhinostomy (DCR) is the standard of care for an NLD obstruction. The surgeon can perform a DCR percutaneously by way of a facial incision or endoscopically via the natural opening of the nose. The procedure is designed to bypass the obstructed nasolacrimal duct and enable tear drainage directly into the nose from the lacrimal sac.
Coders will select the root operation based on the intent of the procedure. Codes include:
- 081X3Z3, Bypass of right lacrimal duct to nasal cavity, percutaneous approach
- 089Y80Z, Drainage of left lacrimal duct, using a drainage device, via natural or artificial opening endoscopic approach
Or the physician may perform dilation of the duct and insertion of a stent, in which case codes include:
- 087X8DZ, Dilation of the right lacrimal duct, with intraluminal device, via national or artificial opening endoscopic
- 087Y8DZ, Dilation of the left lacrimal duct, with intraluminal device, via national or artificial opening endoscopic
Again, if the physician performs the procedure bilaterally (and ICD-10-PCS doesn’t include a bilateral option), report two codes.
Editor’s note: Safian, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.