Ophthalmology and Optometry Coding Alert

So often patients call and request an appointment for blurry vision. When they get into the exam room, the technician asks them why they are there, and they say, I have blurry vision. They dont say, I need new glasses or I need to have my vision checked. This could be an important distinctionMedicare and most private insurance companies pay for medical problems which are causing blurry vision, but not for refraction problems. Yet, the distinction between blurry vision and needs glasses may be irrelevant in reimbursement terms: payers assume that nine times out of ten, they mean the same thing.

Patients think that blurry vision sounds more medical than I need my glasses changed, says Kimberly Fennell, CPC, assistant administrator for Baptist Eye Surgeons, a nine-ophthalmologist practice in Knoxville, TN. Thats why its really important to have a good technician who asks the right questions.

You wont get paid for the visit by Medicare or most commercial carriers if the patient has blurry vision because he or she needs a new prescription for lenses. But if there are other possible reasons, you can code the visit so that you can get paid, Fennell explains.

A chief complaint of blurred vision often doesnt work any more, Fennell says. You have to have some findings. And the findings dont only come from the ophthalmologists examinationthey can come from the history as well.

The chief complaint is recorded not when the patient calls in to make the appointment, but when the technician (or ophthalmologist) takes the history, says Fennell. When the technician asks, Why are you here? the answer is the chief complaint, she says. But the technician has to dig a little farther, and has to know which questions to askpatients dont know what relates to certain symptoms.

For example, a patient might have glaucoma in his or her family history. Sometimes this even skips a generation. A patient may have an angle recession, which could foreshadow glaucoma in the future; coupled with a family history and blurred vision, this would clearly warrant a medical visit which would be reimbursable, says Fennell. Even family history alone would qualify, she adds. These patients may need to be tested for glaucoma on a regular basis. Thats why its so important to get a really detailed history on every patient, she notes.

Another complaint which can be elicited by a careful technician is pain. Of course, you are not trying to put words in the patients mouth, but sometimes patients have a hard time describing exactly what sensation they are experiencing when they have blurry vision. Pain in the eye (379.91) can always be used as a diagnosis, says Fennell. Many other symptoms may be reported by the patient if you start querying the nature of the blurred vision. For example:

368.10: subjective visual disturbance
368.11: sudden visual loss
368.12: transient visual loss
368.13: visual discomfort (asthenopia,
photophobia, eye strain)
368.14: visual distortions of shape and size
368.15: other visual distortions and entopic
phenomenon

The examination can reveal some causes of the blurriness as well. For example, says Fennell, lets say the patient had a preexisting cataract, which has already been operated on. The patient had a cataract extraction and an intraocular lens implanted, she says. But now the capsule is clouding up. You could use the diagnosis code 366.53 for after cataract obscuring vision, which would be resolved by a laser procedure.

The examination could also show that the patient has a foreign body in the eye, which could be causing the blurry visionand pain as well.

Theres one important caveat about this story. Blurry vision is much better than I need glasses if, in fact, the patient does have a medical problem. Thats because no matter what the problem is, if the patient limits it to needing glasses as the chief complaint, you wont get paid unless there is a vision rider. If a patient comes in and says all he or she needs is new glasses to improve blurry vision, and the patient actually has a family history of glaucoma, or a cloudy capsule, or a foreign body, then you still cannot bill for the medical visit. Medicare and many other medical insurers do not cover routine

examinations. Routine is usually defined as services which occur in the absence of a patient reported symptom or sign or a known diagnostic condition requiring periodic reevaluation.