A 50 year-old male presents himself after being referred by his primary care provider for glaucoma. During his preventive medicine visit, he complained of loss of peripheral vision. It came on slowly and is noted in both eyes. He denies eye pain. Patient admits that he does not receive regular eye examinations.
On physical exam, the patient is in no acute distress without eye complaints other than peripheral vision loss. The following tests were performed:
Tonometry, perimetry, gonioscopy, and pachymetry. Ophthalmoscopy indicates increased IOP bilaterally. Test findings are all on attached separate reports.
Assessment: Patient has primary open-angle glaucoma; Mild stage on the right and moderate stage on the left. We discussed different options, including eye drops, oral medications, and laser surgery. The patient wishes to attempt medications first. We have chosen and explained the medication regiment to the patient and he expresses understanding. I will see him again in 2 weeks.
H40.11X2 Primary open-angle glaucoma, moderate stage (for the left eye)
H40.11X1 Primary open-angle glaucoma, mild stage (for the right eye)
Rationale: According to the 2012 ICD-10-CM Official Guidelines/Reporting (C.7.a.3), when a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification does not distinguish laterality, assign one code for each type of glaucoma with the appropriate seventh character for the stage. In the scenario above, the patient has bilateral glaucoma with a different stage in each eye, so two codes must be assigned. Some of the glaucoma code categories in ICD-10-CM contain laterality and some do not.