Ophthalmology and Optometry Coding Alert

ICD-9 codes can make or break the acceptance of a claim. Coding a patient visit for the sole purpose of obtaining payment is asking for trouble, however, particularly in a post-payment review. When is the use of a covered ICD-9 code legitimate, and when may a patient be financially responsible for payment? Pay careful attention to the Medicare rules for diagnosis codes in the following examples.


1. How do we code for patients with resolving conditions? You may think you dont need a medical diagnosis code for a visit from a patient whose condition is resolved, but in the following scenario youll see that you do.

A Medicare beneficiary calls complaining that her right eye is very light-sensitive and the vision seems a little cloudy. You ask the patient to come in the same day for an evaluation. During the conversation with the patient, you discover that she was struck in the right eye by something during a gardening activity the night before. Examination reveals an anterior chamber reaction consistent with traumatic iridocyclitis (364.00). You begin the patient on prednisolone and ask her to return in two to three days. The diagnosis is 364.04 (secondary iridocyclitis, noninfectious).

The same patient returns three days later. She has been faithful with her drops, and her symptoms are considerably better. The anterior chamber reaction is less. You counsel the patient to taper her prednisolone and ask her to return in seven to 10 days. Your chart notes state secondary iridocyclitis resolving. The diagnosis on the fee slip is still 364.04. The iridocyclitis is less severe but still present.

The same patient returns nine days later. She has tapered her drop regimen as directed and is symptom-free. On examination you see no anterior chamber reaction. You ask her to remain off all drops and tell her to return as needed should she have any additional problems. Your chart note says, iridocyclitis resolved.

Do you need a medical diagnosis code when billing this follow-up visit? Remember, the purpose of the ICD-9 code is to explain why the patient is being seen, says Duran. In this case, the physician recommended the patient return to evaluate the secondary iridocyclitis, so 364.04 is the correct diagnosis code for the follow-up visit. Medicare considers a visit to be medically necessary when the patient is seen for a patient complaint of a sign and/or symptom, for a known condition or because the physician recommended a return, says Lise Roberts, vice president of Health Care Compliance Strategies, a coding and compliance consulting firm based in Jericho, N.Y. In the case of a patient presenting with complaint of a sign and/or symptom, notes Duran, if the physician diagnoses a specific medical [...]