Revenue Cycle Insider

Question: I’m new to ophthalmology coding and have an encounter note where the physician diagnosed the patient with acute primary anterior uveitis in the left eye. How do I locate the correct diagnosis code for this patient?

Idaho Subscriber

Answer: Anterior uveitis is a condition where the iris and anterior ciliary body become inflamed. The condition also causes cells and protein to spill into the anterior vitreous and anterior chamber. Anterior uveitis entails iritis and iridocyclitis, which means you’ll want to look for iridocyclitis in the ICD-10-CM Alphabetic Index.

In fact, when you search the Alphabetic Index for Uveitis (anterior) > acute, you’re redirected to “see Iridocyclitis, acute.” Under Iridocyclitis > acute > primary, you’ll find code H20.01- (Primary iridocyclitis), which you’ll then verify in the Tabular List.

However, H20.01- requires a 6^th character to indicate the laterality. Use the following 6^th characters to identify which eye is affected by the condition:

• 1 = right eye
• 2 = left eye
• 3 = both eyes
• 9 = unspecified eye

For your situation, you’ll assign H20.012 (Primary iridocyclitis, left eye) to report the acute primary anterior uveitis of the left eye.

Additional terms: Several conditions are listed under H20.0- (Acute and subacute iridocyclitis) as additional diagnoses that can be reported under the H20.0- code subcategories. These terms include:

• Acute anterior uveitis
• Acute cyclitis
• Acute iritis
• Subacute anterior uveitis
• Subacute cyclitis
• Subacute iritis

You can also use these terms to confirm your physician’s documented diagnosis.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC