Eye examinations

During an eye examination, the physician assesses the visual acuity of the patient. This is accomplished by using a hanging wall chart that the patient reads from a distance of 20 feet. The patient covers one eye and reads the smallest character on the chart. Each eye is tested independently (i.e., one is covered while the other is used to read). The charts are marked with a number at the end of each line (e.g., 100, 200) that provides a comparison of that patient’s vision with that of persons with normal vision. The larger the number, the worse the acuity. For example, 20/100 means that the patient can see at 20 feet what a normal patient could see at 100 feet. A visual acuity chart displaying the classification and descriptions of visual acuity is illustrated in Figure 13-1.

The definitions of a new patient and an established patient are the same as for all patients (less than 3 years since being treated by that physician or another physician of the same specialty who belongs to the same practice group, new; more than 3 years, established). There are two new patient codes and two established patient codes for eye examinations (92002-92014). There are extensive notes before the codes that must be read before coding eye examinations. These notes describe the intermediate, comprehensive, and special ophthalmologic services and should be read prior to coding ophthalmologic services.

Cataracts

There are various types of cataracts, such as senile cataracts linked to the aging process, and many location areas for formation of a cataract, such as anterior or posterior polar cataracts. See Figure 13-2. Reference the term “cataract” in a medical dictionary to see the various types of cataracts. Cataract removal and lens replacement (66830-66990) use three different approaches:

 Extracapsular cataract extraction (ECCE): Partial removal, which removes the hard nucleus in one piece, then removal of the soft cortex in multiple pieces. Extracapsular is on the outside of the eyeball chamber.

 Intracapsular cataract extraction (ICCE): Total removal, which removes the cataract in one piece. Intracapsular is inside the eyeball chamber.

 Phacoemulsification: Dissolves the hard nucleus by means of ultrasound and then the soft cortex is removed in one piece.

CASE 13-3   13-3A Clinic Progress Note, Senile Cataracts

CASE 13-3

As you code the services for this report, the choice of code for the cataract will be based on the age of the patient.

13-3A  Clinic progress note, senile cataracts

LOCATION: Outpatient, Clinic

PATIENT: Margo Himon

PHYSICIAN: Rita Wimer, MD

DIAGNOSIS: Senile cataracts.

FINDINGS: This 69-year-old established patient is in for an exam. Vision is 20/50 and 20/70. Failed driver’s license eye examination. See visual findings as noted. Glass prescription as encircled. Slight improvement in right eye can be obtained by increasing prescription by 0.50 to 0.75 sphere. Applanation reading is 16 bilateral. Medications are listed. Drives daytime only.

TREATMENT: Six to eight months’ fundus. Copy of glass prescription for right lens change. Driver’s license form filled out.

13-3A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

ICD-9-CM DX CODE(S): ___________________________________

CASE 13-4   13-4A Operative Report, Senile Cataracts

CASE 13-4

Phacoemulsification is used in the following cataract surgery.

13-4A  Operative report, senile cataracts

LOCATION: Outpatient, Hospital

PATIENT: Ingrid Cady

ATTENDING PHYSICIAN: Rita Wimer, MD

SURGEON: Rita Wimer, MD

PREOPERATIVE DIAGNOSIS: Senile nuclear cataract, right eye

POSTOPERATIVE DIAGNOSIS: Senile nuclear cataract, right eye

PROCEDURE PERFORMED: Extracapsular cataract extraction by phacoemulsification (Figure 13-3), right eye (model SI40RB, +14.5 diopters, serial no. 38982) and implantation of intraocular lens.

ANESTHESIA: Topical

ESTIMATED BLOOD LOSS: Minimal

COMPLICATIONS: None

PROCEDURE: In the operating room, a drop of lidocaine 4%-MPF was applied to the eye. The patient was prepped and draped in the usual sterile fashion for an intraocular procedure of the right eye. A lid speculum was placed. A Weck-cel soaked with lidocaine 4%-MPF was placed at the limbus, both in the area of the planned phaco incision and planned side port incision. A keratome was used to enter the chamber at the arcade. A small amount of preservative-free lidocaine 1% was injected in the anterior chamber. The aqueous was exchanged with viscoelastic material, and a side port incision was made with a 15-degree angle blade. A continuous tear capsulotomy was made with a bent needle and the Utrata forceps. The nucleus was hydrodissected and removed with phacoemulsification using an ultrasound time of 2.4 minutes and a phaco percentage of 15%. The remaining cortical material was removed with irrigation and aspiration. The capsule was polished and vacuumed as indicated. A small additional amount of lidocaine 1% was again injected into the anterior chamber. Viscoelastic was used to deepen the chamber, and the posterior chamber intraocular lens was unfolded into the capsular bag and dialed into position. Irrigation and aspiration were used to remove the remaining viscoelastic. The globe was pressurized and the cornea hydrated to ensure a good seal. The wound was tested and found to be watertight. TobraDex drops were placed on the surface of the eye. The patient left the operating room in stable condition without complications, having tolerated the procedure well.

13-4A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

ICD-9-CM DX CODE(S): ___________________________________

Photocoagulation

Photocoagulation is the use of laser to seal leaky blood vessels, destroy abnormal blood vessels, destroy abnormal tissue at the back of the eye, and seal retinal tears. The procedure is an office procedure that does not usually require anesthesia other than eyedrops.

Diabetic retinopathy is a condition that manifests by leakage from blood vessels in the retina, causing swelling, which results in decreased vision. Photocoagulation is the treatment of choice for sealing off the leaking vessels.

ICD-10-CM: The Index and Tabular indicate E11.319 for diabetes type 2 with retinopathy.

ICD-9-CM: When reporting the diagnoses for diabetic retinopathy, the Index of the ICD-9-CM will indicate diabetes (250.5x) followed by a retinopathy code in brackets [362.01], which directs the coder to list the diabetes first followed by the retinopathy. Diabetes is the etiology, and retinopathy is the manifestation.

Ectropion and entropion

Ectropion is a condition in which the lower eyelid droops due to age, excessive exposure to the sun, or gravity that relaxes the structures that hold the eyelid in place. The punctum is the drain hole on each lid, near the nose, that drains the tears. However, when the eyelid droops, the tears do not drain naturally into the nose. This leads to deterioration of the protective covering of the eye and results in burning, itching, irritation, and discomfort. Repair of ectropion is reported with codes from the 67914-67917 range. The ectropion repair codes include repair of one eye; if two eyes are done, report the service with modifier -50 to indicate bilateral.

Entropion is a condition in which the lower eyelid turns inward. See Figure 13-4. The eyelashes and skin of the eyelid then rub against the cornea and conjunctiva, which leads to excessive tearing, crusting eyelid, discharge, impaired vision, and irritation of the cornea. Repair of entropion is reported with codes from the 67921-67924 range. The entropion repair codes include repair of one eye; if two eyes are done, report the service with modifier -50 to indicate bilateral.

CASE 13-6   13-6A Operative Report, Entropion and Ectropion Repair

CASE 13-6

Use HCPCS modifiers when reporting the services for this patient.

13-6A  Operative report, entropion and ectropion repair

LOCATION: Outpatient, Hospital

PATIENT: Robert Vobr

ATTENDING PHYSICIAN: Rita Wimer, MD

PREOPERATIVE DIAGNOSIS:

1. Upper lid entropion, both eyes; lower lid ectropion, both eyes

2. Graves’ disease

3. Status post chemical decompression for Graves’ disease

4. Chronic exposure, keratitis secondary to diagnoses 1, 2, and 3

5. Chronic conjunctivitis secondary to diagnoses 1, 2, 3, and 4

POSTOPERATIVE DIAGNOSIS:

1. Upper lid entropion, both eyes; lower lid ectropion, both eyes

2. Graves’ disease

3. Status post chemical decompression for Graves’ disease

4. Chronic exposure, keratitis secondary to diagnoses 1, 2, and 3

5. Chronic conjunctivitis secondary to diagnoses 1, 2, 3, and 4

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