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Question: A patient presented with complaints of blurry vision in their left eye. The ophthalmologist performed a comprehensive eye examination and discovered early signs of cataracts. The physician documented a diagnosis of nuclear sclerosis cataract of the right eye. I’m new to ophthalmology coding — can you help me select the correct codes for the encounter?

Delaware Subscriber

Answer: Absolutely! Let’s start with the diagnosis code. Nuclear sclerosis is another term to describe age-related nuclear cataract. You’ll use H25.12 (Age-related nuclear cataract, left eye) to report the documented diagnosis. Nuclear cataract is a condition where the cataract affects the center (nucleus) of the lens. At first, faraway objects may appear blurry while close-up objects will be in focus. However, over time, the patient’s vision will diminish.

Next, assign 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.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC