Optometry Coding & Billing Alert

Published on Mon Aug 10, 2015 PDF

Question: Our optometrist diagnosed a patient with proliferative diabetic retinopathy as a result of uncontrolled type II diabetes. What ICD-9 code would be the primary diagnosis?

New Mexico Subscriber

Answer: Report ICD-9 code 250.52. ICD-9 guidelines direct you to “code first diabetes.” Report the proper code for the underlying condition (diabetes with ophthalmic condition) as the primary diagnosis. Which code you report depends on the type of diabetes, and whether it’s controlled or uncontrolled:

• 250.50 — Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled

• 250.51 — …type I [juvenile type], not stated as uncontrolled

• 250.52 — … type II or unspecified type, uncontrolled

• 250.53 — … type I [juvenile type], uncontrolled.

As a secondary diagnosis, you would then code the manifestation. For DR, the ICD-9 codes include:

• 362.01 — Background diabetic retinopathy

• 362.02 — Proliferative diabetic retinopathy

• 362.03 — Nonproliferative diabetic retinopathy NOS

• 362.04 — Mild nonproliferative diabetic retinopathy

• 362.05 — Moderate nonproliferative diabetic retinopathy

• 362.06 — Severe nonproliferative diabetic retinopathy

• 362.07 — Diabetic macular edema.

In this scenario (proliferative DR as a result of uncontrolled type II diabetes), the primary diagnosis would be 250.52 and the secondary diagnosis would be 362.02.