Age-related cataract

ataylor77

Contributor
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Our nurses fill out our charges and they rarely specify the type of cataract; for example, they write cataract OS or cataract OD, so I code them H26.9 since they do not specify age-related, etc. Since the CMS has ended their grace period for unspecified codes our manager wants us to use H25.11 or H25.12 even if the nurses do not specify age-related cataract. The information I read is that the CMS requires coders to code as specific as possible according to documentation, and I am certain they do not require specific codes that are undocumented. Does anyone else use age-related cataract if it is not documented? Thanks!
 

Cheezum51

Expert
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In general, unless the patient has diabetes which isn't controlled or is taking medications which could cause premature development of cataracts, I think you could safely assume that anyone 55 or older who has a cataract has an age related cataract for coding purposes.

Tom Cheezum, O.D., CPC
 
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