Ophthalmology and Optometry Coding Alert

If you're not using fifth-digit diagnosis codes to support glaucoma surgery, it shouldn't surprise you when Medicare pulls an Elvis with your next trabeculoplasty claim and returns it to sender. And fifth-digit coding is only a first step to obtaining maximum ethical reimbursement for glaucoma surgeries. The 2002 Medicare glaucoma screening benefit has ophthalmology coders bombarded with tips on how to correctly code Medicare patients' screenings (see "Know When to Use Glaucoma Screening Codes Versus E/M or Eye Codes" in the April 2002 issue and "News Brief: CCI 8.0 Includes Eyelid Reconstruction, Screening" in the February 2002 issue of Ophthalmology Coding Alert), but coders may be wondering how to code glaucoma surgical procedures for those patients discovered to be in the advanced stages of the disease. But you can accurately code glaucoma surgery from start to finish if you follow these three easy steps. Step 1: Prediagnose and Diagnose With Specific ICD-9 Codes When diagnosis coding for glaucoma, "it is imperative we go to the fifth digit to get the best reimbursement," says Fiona Lange, CPC, with Danbury Eye Physicians, a nine-physician multi-specialty practice in Danbury, Conn. Fifth-digit coding also maximizes the chance you will be paid with the first claim. You must use the fifth digit for glaucoma diagnoses or "Medicare will send [a claim] back as unprocessable," according to Tracy M. Trout, CPC, coding specialist for Apple Hill Eye Center in York, Pa. Medicare's clean-claim requirements demand that you code to the highest level of specificity.

"Because most cases we see, especially surgically, are chronic problems with complications associated [with glaucoma], you need to be absolutely specific all the way because some of the complications are not necessarily normal post-op," Lange says. "If we're trying to rebill for other surgeries, more extensive surgeries after the fact, then we absolutely do need to make sure we are as specific as possible."

Even when the ophthalmologist is seeing a patient who is a "glaucoma suspect," you have fifth-digit-specific coding options for signs and symptoms diagnosis coding that payers are more likely to reimburse you for than if you use 365.00 (Preglaucoma, unspecified). These preferred codes include 365.01 (Open angle with borderline findings), 365.02 (Anatomical narrow angle), 365.03 (Steroid responders) and 365.04 (Ocular hypertension). After the ophthalmologist makes a definitive diagnosis, you should use an even more specific diagnosis code. Ophthalmologists have a smorgasbord of primary diagnosis codes that constitute medical necessity for glaucoma: 365.11-365.9.

Avoid using less specific codes like 365.10 (Open-angle glaucoma, unspecified). Patients with advanced glaucoma require frequent visits to the ophthalmologist, and unspecified codes like 365.10 don't always make the grade as grounds for medical necessity when insurers examine claims. Step 2: Choose Procedure Codes Carefully The [...]