Family History of glaucoma

Tacoma, WA
Best answers
Hi everyone: I am in need of feedback on a coding issue. Our billing department is asking why family history of glaucoma can not be used as a primary diagnosis code. In reading the visit notes the patient is a 3 yr old child with a higher risk of glaucoma due to Father having pediatric glaucoma. On a comprehensive eye exam IOPs are checked and are normal. Assessed diagnoses are refractive error codes only. The parent wants the codes changed so the claim goes to the medical benefits not vision. I don't agree with a code change but I can not find anything that says Family history of glaucoma can not be a primary diagnosis.

Thanks for any help and feedback you can offer.
Personally, I would think that the exam would have to show some other risk factors for glaucoma, such as elevated IOP or optic nerve changes, to qualify for the "medical necessity" necessary to bill the exam to medical insurance. Then you could bill for the patient having a high risk for glaucoma.

If a person had a family history of hypertension but had no signs of it themselves, you can't bill medical based upon the family history. Same applies to your case.

Tom Cheezum, O.D., CPC
History (of)

According to the guidelines, the codes for Personal history or Family history: "are also acceptable on any medical record regardless of the reason for the visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered." {Emphasis added} A person with a family history of a disease such as glaucoma is at higher risk of developing said disease, hence the need for careful screening.

David Keown, CPC, OCS
dkeown, I agree that family medical history is an important part of the medical record. However, as a provider for 38 years, the fact that a patient has a family history of glaucoma never automatically caused me to bill the visit as medical unless I found other things during the patient exam which increased the risk of that patient actually having glaucoma or being at a higher risk for it.
Having the family history of glaucoma in the record is just one factor that has to be considered but it, by itself, in my opinion, doesn't elevate the exam to a level of medical necessity which would allow it to be billed to medical insurance.

One thing I always took into account as a provider was to be very careful not to put a questionable diagnosis into a patient's medical record because of the potential long term consequences to them in terms of insurance coverage and cost. I was the "victim" of improper information put into my medical record by a provider which labeled me as a high cardiac risk patient which cost me tens of thousands of dollars in extra premiums until I could finally get an underwriter to properly evaluate my medical record and remove that label.

Perhaps the ACA has helped with that to a certain extent, but I think the jury is still definitely out on that one between the outrageous deductibles and the crazy annual premium increases.

Tom Cheezum, O.D., CPC
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