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Diagnosis Coding for Well Eye vs Sick Eye

  1. #1
    Unhappy Diagnosis Coding for Well Eye vs Sick Eye
    Medical Coding Books
    If a patient schedules a well eye appointment but after examination the provider discovers a problem and it now becomes a sick eye, would the provider code the well eye dx for the reason for the encounter as well as the sick eye dx? I mostly deal with CPT so I'm a bit rusty with dx coding. I think the dx would be the sick eye only as it is the reason after study for the encounter. Am I correct? Thank you!!

  2. #2
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    If the visit is preventive with no complaints and the provider discovers a problem, then the reason for the visit has not changed it is still preventive with an incidental finding, since the patient did not have the provider specifically looking at a symptomatic problem. Incidental findings are always listed second.

    Debra A. Mitchell, MSPH, CPC-H

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