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Question: A 65-year-old new patient presented with floaters in their vision. The optometrist performed a comprehensive dilated eye exam and diagnosed posterior vitreous detachment. The patient was advised to monitor for changes.

I’m new to optometry coding, and I’m not sure codes to report. Can you help?

Wyoming Subscriber

Answer: Sure! Let’s start with the CPT^® code. Use 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits) to report the comprehensive eye examination.

Next, you’ll open the ICD-10-CM code book. Turn to Disease > vitreous > specified NEC, and then you’ll turn to the Tabular List to verify the code. In the H43.8- (Other disorders of vitreous body) subcategory, you’ll find vitreous detachment is an additional term listed under H43.81- (Vitreous degeneration). You’ll need a 6^th character to specify the laterality, so use H43.811 (Vitreous degeneration, right eye) as your complete diagnosis code.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC