Ophthalmology and Optometry Coding Alert

When diabetes leads to vision issues, patients are likely to come to your office more than once a year. For correct ICD-10-CM coding, you’ll have to know not only the nature of the ophthalmic complication, but the nature of the underlying diabetes itself. Check out these quick tips to ensure that you report your diagnosis codes correctly.

Don’t Limit Yourself to E11.9

Don’t make the common coding mistake of reporting E11.9 (Type 2 diabetes mellitus without complications) for every situation. This code alone generally is not sufficient to indicate the ophthalmic manifestations of diabetes, and actually contradicts a diagnosis of diabetes with ocular manifestations. Instead, you must specify the exact type of diabetes for which the ophthalmologist is providing care, as well as the eye symptoms that the patient is experiencing.

In black and white: The 2022 ICD-10-CM Guidelines state, “The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.” This will often mean that you have to code out to six or seven characters to fully describe the condition that your eye care specialist evaluated.

Check Combination Codes

Your best bet is to use combination codes that describe both the ophthalmic manifestation and the diabetes, and this combo is already covered in the “Diabetes with Ophthalmic Manifestations” ICD-10 codes. The E11.3-- (Type 2 diabetes mellitus with ophthalmic complications) range of codes specifies type 2 diabetes mellitus, with specific codes detailing the type and severity of ophthalmic complication. Keep in mind that some of these codes require a seventh character, says Mary Pat Johnson, COMT, CPC, COE CPMA, senior consultant with Corcoran Consulting Group:

• E11.311 (Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema)
• E11.319 (... without macular edema)
• E11.321 (Type 2 diabetes mellitus with mild nonprolif­erative diabetic retinopathy with macular edema)
• E11.329 (... without macular edema)
• E11.331 (Type 2 diabetes mellitus with moderate nonpro­liferative diabetic retinopathy with macular edema)
• E11.339 (... without macular edema)
• E11.341 (Type 2 diabetes mellitus with severe nonprolif­erative diabetic retinopathy with macular edema)
• E11.349 (... without macular edema)
• E11.351 (Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema)
• E11.359 (... without macular edema)
• E11.36 (Type 2 diabetes mellitus with diabetic cataract)
• E11.39 (Type 2 diabetes mellitus with other diabetic ophthalmic complication)

The E10.3 (Type 1 diabetes mellitus with ophthalmic complications) series is similarly broken down with specific ophthalmic manifestations.

However: Not all ophthalmic manifestations are covered in the E10.3 and E11.3 series. For example, E10.39 (Type 1 diabetes mellitus with other diabetic ophthalmic complication) contains an instruction to “use additional code to identify manifestation, such as: diabetic glaucoma (H40-H42).” Therefore, always read the notations that are listed following the specific diagnosis codes in the ICD-10 listing to know whether you should be using additional codes.

Remember to Change Gears for Type 1

Remember that not all diabetes patients have type 2 diabetes mellitus. You may see patients whose eyes are impacted by the effects of type 1 diabetes, and you’ll look to the E10.3x (Type 1 diabetes mellitus with ophthalmic complications) series when seeing patients in this category.

For instance, if you see a patient who has type 1 diabetes and mild diabetic retinopathy with macular edema in the right eye, you’ll report E10.3211 (Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye).

“For patients with type 2 diabetes mellitus (E11.xx), use of oral medications or insulin should be identified with the appropriate ICD-10 code,” Johnson says.