Revenue Cycle Insider

Question: Our ophthalmologist diagnosed a patient with primary open-angle glaucoma (POAG), but the right eye is documented as moderate stage and the left eye is noted as severe stage. Should we use a bilateral diagnosis code, or do we report each eye individually?

Texas Subscriber

Answer: You will assign a separate code for each eye for this case. Assign H40.1112 (Primary open-angle glaucoma, right eye, moderate stage) to report the moderate stage POAG in the right eye. Use H40.1123 (Primary open-angle glaucoma, left eye, severe stage) to report the severe stage POAG of the left eye.

POAG codes are listed under the H40.11- (Primary open-angle glaucoma) code subcategory. A 6^th character indicates the laterality, so H40.111- (Primary open-angle glaucoma, right eye) is designated for the right eye and H40.112- (Primary open-angle glaucoma, left eye) identifies POAG in the left eye.

This subcategory also requires a 7^th character to complete each code. The 7^th characters below identify the stage of glaucoma:

• 0: stage unspecified
• 1: mild stage
• 2: moderate stage
• 3: severe stage
• 4: indeterminate stage

The 7^th character 0 (unspecified) and 7^th character 4 (indeterminate) are not interchangeable. You’ll use 4 when the documentation states that the stage cannot be clinically determined. Use 0 when the physician does not identify the stage in the medical record.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC