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Coding & Billing: Top ICD-10 Challenges for Eye Cases
Be on the lookout for these common coding errors.
Sue Vicchrilli
Publish Date: November 3, 2015   |  Tags:   Financial Management
eye procedure CODING COMPLAINTS There are several major changes in ICD-10 that impact your eye procedure claims.

It's been about a month since the switch to ICD-10 and you're (hopefully) starting to get reimbursements for your eye procedures. But if you're getting denials instead, check to see if one of these common challenges is bungling up your ophthalmic claims.

  • Diabetic patients. One of the most notable changes in ICD-10 is the coding for persons with diabetes. ICD-9 documentation for non-insulin-dependent diabetes mellitus (or NIDDM) does not easily translate to ICD-10. While your docs can document NIDDM in their op notes for ICD-10, language such as "controlled" or "uncontrolled," and "juvenile-onset" or "adult-onset" is obsolete.

What used to be potentially 3 separate ICD-9 codes is now a single, specific ICD-10 code (E10-E14). This code lists (1) the type of diabetes, (2) the existence of retinopathy (as well as the type and severity) and (3) whether the patient has macular edema. For example, Type 1 diabetes mellitus without complications is coded as E10.9, while E10.349 represents Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy, without macular edema. Note that since there is no laterality indicated in this code, the patient could have a different type in each eye.

Coders should pay special attention when coding a diabetic condition to ensure that it's specific enough and uses the correct code for each characteristic of the diabetes. The American Academy of Ophthalmology has created a diabetes decision tree to help in this regard (osmag.net/5EmKRx).

  • X placeholders. Glaucoma staging and injury and trauma diagnoses require a 7th character in ICD-10. However, not all ICD-10 codes that require a 7th character have a 6th character, and they may even be missing a 5th. To ensure that the coding is in the correct position, you use an X placeholder.

If you're using a code that's only 5 digits long but requires a 7th character, place an X between the 5th and 7th character. For example, to code for primary open-angle glaucoma (POAG), moderate stage, you would use the code H40.11X2, with the X in the 6th character spot. H40 represents glaucoma, 11 indicates POAG and since the 2 (which indicates moderate stage) must be in the 7th position, you place the X in the 6th spot. Without the correct use of this placeholder, your claim could be delayed or denied.

  • Laterality. As seen with the diabetes example above, not all codes in ICD-10 include laterality. So, it's imperative to know when an additional character is required. While some codes ask you to add the laterality — which you do by tacking on a 1 for the right side, 2 for the left side and 3 for bilateral to the end of the code — others don't require it. There is no rhyme or reason to this, so consult with your codebook or other resources if you are unsure.

For example, in ICD-9 a central corneal ulcer was coded as 370.03. In ICD-10 that could be coded 3 different ways: H16.011 if it's the right eye, H16.012 in the left eye or H16.013 in both eyes. Leaving off an additional digit, or adding one when it does not belong, may cause a claim to be delayed or denied.

  • Increased specificity. Another big change with ICD-10 is that a surgeon's operative reports must be much more specific than he may be used to. For instance, glaucoma surgeons will need to identify whether the glaucoma stage is mild, moderate or severe so it can be coded correctly — using 7th digits 1, 2 and 3, respectively.

In cataract surgery, physicians will need to be much more specific in the type of cataract being removed. Note that there are 70 options for cataracts in ICD-10, so rather than stating "cataracts" as the diagnosis, the surgeon's chart and reports must accurately reflect the type. If you're submitting a claim for "complex cataract surgery," be sure to add additional diagnosis indicating why the case meets the criteria for "complex." For example, the Medicare Administrative Contractor Novitas' Local Coverage Determination (osmag.net/XSueD8) includes a list of additional diagnoses that qualify as complex cases. This includes the use of micro iris hooks inserted through 4 separate corneal incisions, when a Beehler or similar expansion device is used, or when the IOL was supported by using permanent sutures or a capsular support ring.

Overall, greater specificity will be required to correctly code nearly every diagnosis and procedure. Let's look at the example of a patient with a retinal tear in the right eye. If the surgeon repairs the retinal break using photocoagulations, the CPT code is 67145-RT. But the type of tear offers several choices:

  • H33.311 Horseshoe tear without detachment, right eye
  • H33.321 Round hole without detachment, right eye
  • H33.331 Multiple defects without detachment, right eye

Having thorough and detailed op reports is obviously essential in order for your staff to choose the correct code.

If you still need help
The ICD-10 transition isn't a one-and-done thing. For the first few months, having an ICD-10 codebook and other resources easily accessible is imperative for these tricky situations. You'll also find several free resources on the American Academy of Ophthalmology's website (aao.org/icd10). Once you start receiving reimbursements and denials, be sure to closely monitor them for any denial trends — they may be related to the common problems listed above.