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Ophthalmology and Optometry Coding Alert

Reader Question:

Does Old BB Gun Injury Have Bearing on Coding?

Published on Thu May 28, 2009

Question: We have a patient who came in for a routine eye exam, but reported retinal damage from a BBgun incident six years ago. What would be the best way to code this? This is a new patient, and I do not have any old records. Montana Subscriber Answer: Unless the patient is presenting with symptoms or problems specific to the BB-gun injury six years ago, it may not have any bearing on your coding. The diagnosis code always depends on the reason for the visit. If the patient decided to see an ophthalmologist because of eye pain, eye pain (379.91, Pain in or around eye) -- or whatever the ophthalmologist found that was causing the pain -- would be the diagnosis. If the eye pain is indeed the late effect of the BB-gun injury, you could report 906.0 (Late effect of open wound of head, neck and trunk) as a secondary [...]
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