Ophthalmology and Optometry Coding Alert

Question: A 12-year-old patient presented to our eye care practice after failing a school vision screening. The optometrist noted no issues with the patient’s vision and determined that the patient had no abnormalities. Which diagnosis code applies?

New Jersey Subscriber

Answer: In this situation, you’ll turn to the Z01.0 (Encounter for examination of eyes and vision) category, where you’ll find codes that describe the eye care physician’s encounter with the patient following a failed vision screening.

For the case described, you’ll report Z01.020 (Encounter for examination of eyes and vision following failed vision screening without abnormal findings). This six-character code not only tells the insurer that you saw the patient as a follow-up to a prior failed vision screening, but it may also justify a screening if you already performed one on the same patient within the prior year. The code would tell the payer exactly why you performed it again.