Ophthalmology and Optometry Coding Alert

Selecting the correct diagnosis code or codes to link to a procedure depends partly on the patient's chief complaint. Coders must know when to rely on the chief complaint and when to rely on the final diagnosis for each procedure or service. In ophthalmology, when so many minor procedures are done at the same time as an office visit, it's essential to choose ICD-9 codes that are as accurate and specific as possible. The diagnosis gets the claim paid, and an incorrect diagnosis may lead to rejection of a claim for lack of medical necessity. Choose a diagnosis based on the information obtained, not just to get paid that is fraud.
 
Only a physician can choose the diagnosis. However, the chief complaint an essential part of office visit coding is often documented by the technician, who, in ophthalmology, often conducts an extensive interview with the patient prior to the doctor's examination, and elicits the chief complaint.
 
But sometimes the chief complaint surfaces after the technician interview. Perhaps, during a test or the ophthalmologist's examination, the patient recalls a problem. Therefore, many consultants recommend leaving the chief complaint blank until after the examination if the patient does not offer one during the history, says Sherry Searson, CPC, an independent coding and billing ophthalmology consultant in Charleston, S.C.
Related Chief Complaint and Final Diagnosis
Frequently, the chief complaint code and the diagnosis code are different but related. For example, a patient may complain of pain in the eye (379.91, unspecified disorder of eye and adnexa; pain in or around eye), and the physician discovers a significantly elevated intraocular pressure (IOP) (365.xx). The elevated pressure is causing the pain. The billing diagnosis should always be the definitive diagnosis, if there is one, unless the patient has no complaint at all.
Two Chief Complaints, Two Diagnoses
Sometimes the diagnosis for an office visit is entirely different from the reason that the patient came to the office. For example, a patient complains of dry itchy eyelids. The technician, noticing that the patient's last visit was almost a year ago, asks other questions unrelated to the eyelids, including general vision questions. The patient says, "Oh yes, in fact I am having a problem driving at night it's the glare." There are two chief complaints. The ophthalmologist, based on the vision complaint, performs a complete eye exam (92014) and discovers incipient cataracts. The physician also treats the eyelid problem, which is caused by blepharitis. Use the vision problem (368.xx, visual disturbances) as the primary diagnosis, and the blepharitis as the secondary diagnosis (373.0x). Without the chief complaint of vision problems, the physician would have only performed a problem-focused visit, billing 99212 or perhaps 99213. (And the patient's cataracts would [...]