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Wiki Ocular HTN vs PreGlaucoma

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DJZito

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Local Chapter Officer
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Sumter, SC
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If the provider states in his assessment Ocular HTN vs Pre-Glaucoma, do you code both? I am new to coding Optometry visits.
 
If the doctor is giving a "possible, probable or maybe" dx I don't code them. In this case the doctor is not sure if it's 365.04 or 365.00, so I wouldn't use either. I would go back to the doctor and ask if there is any symptoms that can be coded----increased ocular pressure, or large cupping of the disc???
 
'vs' means there is not a definitive diagnosis. Ocular hypertension (ICD-9 365.04) can be coded if there are at least two visits with IOP >21 mm Hg in same eye with no optic disc changes. Preglaucoma (ICD-9 365.00) cannot be coded unless there is a definitive diagnosis of 'preglaucoma' written on the encounter. If there is cupping of optic discs >0.6 C/D ratio, or there mention of 'borderline increased IOP', then you can use CPT 365.01. That is my opinion for what it's worth.
 
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