Pre-senile cataract removal in adult patient

Kristen Bensel

Networker
Messages
64
Location
Pilot rock, OR
Best answers
0
Good Afternoon.
I am trying to find guidance on how to properly code a pre-senile cataract that was removed for a 21 year old patient. The encounter was for a cataract global transfer of care, and coded as the surgical center coded the procedure. The encounter was billed with the juvenile cataract code, and denied for patient age.

The patient was diagnosed in childhood with juvenile cataracts, so, how do I code this if the proper code for the condition is not allowed on an adult patient? It seems incorrect to code it with a unspecified code, or one that is not what the patient actually had. Unless the pre-senile cataract is changed to a senile cataract because the patient is now the age of an adult...

Any guidance anyone can send my way is greatly appreciated. Thank you.
 

fwnewbie

Guest
Messages
541
Location
New Haven, IN
Best answers
0
I would want to have more info: was this considered a congenital cataract?, caused by medication/oxygen use as infant or child? diabetes? other metabolic disease? Is there any descriptive terms about the cataract like cortical or nuclear? Any of these terms could help pinpoint the category of presenile cataract.
I don't know what age includes juvenile.
 
Messages
2,169
Location
Clovis, CA
Best answers
3
Juvenile cataracts is only reported in patients aged 0-17. Once the patient is over 18, the code is no longer used. It appears to not be about onset, but about the current age of the patient.
 

thomas7331

True Blue
Messages
4,416
Best answers
13
'Pre-senile cataract' codes to the H26 category in ICD-10 - I could be mistaken, but I'm not aware of any coding guideline that puts an age limit on the use of these codes or that would allow you to code something different if that is in fact what is documented.

I suspect this is a payer issue - payers do sometimes build edits into their system that aren't necessarily correct. If the payer does not have any specific clinical or reimbursement policy published to guide you on this, and there is not a specific coding rule that they can cite to support the denial, then they need to overturn it. If your provider has confirmed that the diagnosis is correct, then I would escalate this with the payer.
 
Last edited:
Messages
2,169
Location
Clovis, CA
Best answers
3
Great table! So pre-senile is adult to age 65.
The original question keeps leading back to there needs to be some indication of the stage of cataract or physical descriptor ie cortical, nuclear, etc. imo

Oh yes, I agree. I'm just saying that age matters. For instance, children with juvenile arthritis, if they don't outgrow it, don't keep the juvenile arthritis diagnosis. It moves on to adult arthritis.
 

thomas7331

True Blue
Messages
4,416
Best answers
13
I think we're confusing diagnosis with code descriptor here. In this scenario, the diagnosis is 'pre-senile cataract'. ICD-10 maps this to H26 which has a descriptor of 'infantile and juvenile cataract' and there is no exclusion note that would direct to a different code for an age-specific condition. In this case, the term 'juvenile' is in the descriptor, not the diagnosis. The descriptor is just the name of the classification where the diagnosis is reported - it is not the diagnosis itself. I believe it is coded correctly based on the information given here.

SNOMED CT is not a source that is commonly used by organizations for guidance in ICD-10 coding and wouldn't likely support bypassing standard coding guidelines. But even if it was, the age chart here shows that pre-senile is a valid diagnosis for the patient's age. The issue is not with the diagnosis, it's with the fact that the payer is placing an incorrect age-related edit onto a diagnosis code which is valid, which they are likely doing because they are looking at the coder descriptor and not the diagnosis itself.
 
Top