Ophthalmology and Optometry Coding Alert

ICD-10:

Forgetting Stage on Glaucoma Claims Could Cost You

Published on Thu Jun 23, 2016

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Stay on top of the extended descriptors to ensure you can collect for your services.

You probably know that you need to code your eye care services to the highest level of specificity, but you may not realize that this includes the stage of your patient’s glaucoma. If you leave the stage off of your claim, your payer is likely to deny the charges.

Auditors from Part B MAC Palmetto GBA reviewed claims last fall to determine whether diagnosis codes were submitted as specifically as possible—but in most cases, they fell short. This is especially troublesome in light of the fact that the ICD-10 “grace period”—during which MACs do not deny claims with the wrong ICD-10 codes, as long as the codes are from the right “family.” However, that grace period ends on Sept. 30, and there’s a strong chance that denials will increase thereafter if your claims aren’t as accurate as possible.

Recent Reviews Spell Trouble

During a 2015 audit of ophthalmology claims, Part B MAC Palmetto GBA determined that 60 percent of the claims submitted with a diagnosis of glaucoma requiring a stage were not coded appropriately, said Palmetto GBA’s Cyndi Wellborn, RN during a November 2015 webinar explaining the findings of a Comparative Billing Report. “Providers should assign as many codes from category H40 (Glaucoma) as necessary to identify the type of glaucoma, the affected eye, and the stage,” she said.

Your documentation should include the stage of glaucoma—if you don’t know it, document that as well, she added. In that case, you’ll use the seventh character of “4” (Indeterminate stage). For instance, H40.1224 (Low-tension glaucoma, left eye, indeterminate stage).

Know These Facts About Stages

You may not have pored over the 115-page list of rules titled “ICD-10-CM Official Guidelines for Coding and Reporting FY 2016,” but these Guidelines actually spell out just how to tackle some of the most common coding dilemmas related to glaucoma staging, including the following:

1. Remember You Report One Code Now. Under ICD-9, you had to report one code to describe the type of glaucoma, and a second code to define the stage of glaucoma. For instance, a patient with mild stage glaucoma would require one code for the glaucoma type (for example, 365.11, Primary open-angle glaucoma) followed by 365.71 (Mild stage, glaucoma).

Now that same condition would be coded with H40.11X1 (Primary open-angle glaucoma, mild stage). Although this makes coding easier in a way because you no longer have two codes to look up, it also requires a little bit of extra time ensuring that you report seven characters. Any truncated codes will likely be denied.

2. Nail Down the Stages. The seventh character digits that define the stages are as follows, based on the ICD-10-CM Manual:

0: Stage unspecified
1: Mild Stage
2: Moderate stage
3: Severe stage
4: Indeterminate stage

3. Sometimes You May Need Separate Codes for Each Eye. According to the 2016 guidelines, you should adjust how you code when a patient has different types of glaucoma in each eye:

“When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma,” the Guidelines say. “When a patient has bilateral glaucoma and each eye is documented as having a different type, and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), assign one code for each type of glaucoma with the appropriate seventh character for the stage.”

If, however, the patient has bilateral glaucoma represented by the same type in each eye but different stages and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), “assign a code for the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye,” the guidelines advise.