ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity

Chapter 7

DISEASES OF THE EYE AND ADNEXA (H00-H59)

Introduction

The codes for diseases of the eye are located in Chapter 7 Diseases of the Eye and Adnexa (H00-H59).

The chapter begins with instructions to assign an external cause code following the code for the eye condition to identify the cause of the eye condition when applicable. Along with codes for diseases of the eye, are also codes for diseases and conditions affecting the adnexa, or the structures surrounding the eye, such as the tear (lacrimal) ducts and glands, the extraocular muscles, and the eyelids.

Coding diseases of the eye and adnexa can be difficult due to the complex anatomic structures of the ocular system. Provider documentation specifying the affected site is required in detail as body sites very specific and require documentation of laterality for paired body parts and of upper versus lower sites as in right upper eyelid or right lower eyelid.

Documentation of the evaluation and treatment of eye disorders can be difficult to understand because ophthalmology has a distinctive language. Most ophthalmic terminology such as amblyopia, glaucoma, chalazion, and pterygium are derived from Greek and Latin words. For example, ophthalmologic medical record documentation often indicates “O.S.” and “O.D.” O.S. is an abbreviation for “oculus sinister,” Latin for “left eye” and O.D. is an abbreviation for “oculus dexter,” Latin for “right eye”.

To help understand the coding and documentation requirements for diseases of the eye and adnexa the code blocks in ICD-10-CM are displayed in the following table.

ICD-10-CM Blocks
H00-H05	Disorders of eyelid, lacrimal system and orbit
H10-H11	Disorders of conjunctiva
H15-H22	Disorders of sclera, cornea, iris and ciliary body
H25-H28	Disorders of lens
H30-H36	Disorders of choroid and retina
H40-H42	Glaucoma
H43-H44	Disorders of vitreous body and globe
H46-H47	Disorders of optic nerve and visual pathways
H49-H52	Disorders of ocular muscles, binocular movement, accommodation and refraction
H53-H54	Visual disturbances and blindness
H55-H57	Other disorders of eye and adnexa
H59	Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified

There is also a code block to classify all intraoperative and post procedural complications of treatment for eye and adnexal disorders.

Exclusions

There are no Excludes1 notes, but there are a number of Excludes2 notes, which are listed in the table below.

Excludes1

Excludes2

None

Certain conditions originating in the perinatal period (P04-P96)

Certain infectious and parasitic diseases (A00-B99)

Complications of pregnancy, childbirth and the puerperium (O00-O9A)

Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)

Diabetes mellitus related eye conditions (E08.3-, E09.3-, E10.3-, E11.3-, E13.3-)

Endocrine, nutritional and metabolic diseases (E00-E88)

Injury (trauma) of eye and orbit (S05.-)

Injury, poisoning and certain other consequences of external causes (S00-T88)

Neoplasms (C00-D49)

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)

Syphilis related eye disorders (A50.01, A50.3-, A51.43, A52.71)

As can be seen in the exclusions table, several diseases coded to other chapters have associated eye manifestations, such as eye disorders associated with infectious diseases (Chapter 1) and diabetes (Chapter 4). ICD-10-CM contains many combination codes for conditions and common symptoms or manifestations. Most notably, there are combination codes for diabetes mellitus with eye conditions (E08.3-, E09.3-, E10.3-, E11.3-, E13.3-) such as diabetic retinopathy.

Besides diabetes related conditions and eye disorders associated with infectious and parasitic diseases, other disorders of the eye and adnexa are classified in different chapters, such as conditions associated with a neoplastic process, conditions originating in the perinatal period (P04-P96), complications of pregnancy, childbirth and the puerperium (O00-O9A) and congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99). Conditions resulting from injury or trauma to the eye and orbit (S05.-) are classified in Chapter 19 - Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88).

Chapter Guidelines

Coding and sequencing guidelines for diseases of the eye and adnexa and complications due to the treatment of these conditions are found in the coding conventions, the general coding guidelines, and the chapter-specific coding guidelines. Close attention to the instructions in the Tabular List and Alphabetic Index is also needed in order to assign the most specific code possible.

There are specific guidelines addressing assignment of glaucoma codes. For example, when a patient is admitted with glaucoma and the stage evolves during the admission, coding guidelines direct the user to assign the code for the highest stage documented. Another example involves assignment of the code for “indeterminate” stage glaucoma; guidelines state that code assignment is based on the clinical documentation. Glaucoma codes are combination codes and the seventh character “4” is assigned for glaucoma cases whose stage cannot be clinically determined. Coding guidelines caution the user not to confuse the indeterminate stage with unspecified stage which is assigned only when there is no documentation regarding the stage of the glaucoma.

Codes identify the type of glaucoma, the affected eye, and the glaucoma stage in a single combination code. Laterality is a component for choosing codes. There are guidelines for coding bilateral glaucoma:

•For bilateral glaucoma where both eyes are documented as the same type and stage, and there is a code for bilateral provided, a single code for the type of glaucoma, bilateral, is reported with the seventh character identifying the stage.

•For bilateral glaucoma where both eyes are documented as the same type and stage, and the classification does not provide a code for bilateral glaucoma (e.g. H40.10, H40.20), report only one code for the type of glaucoma with the appropriate seventh character for stage.

Different types or stages

•When each eye is documented as having a different type or stage in bilateral glaucoma, assign the appropriate code for each eye when laterality is distinguished

•When each eye is documented as having a different type or stage in bilateral glaucoma, and laterality is not distinguished, assign one code for each type of glaucoma present with the appropriate seventh digit

•When each eye is documented as having the same type but different stage in bilateral glaucoma, and laterality is not distinguished, assign a code for the type of glaucoma with the appropriate seventh digit for each eye

General Documentation Requirements

Documentation requirements depend on the particular disease or disorder affecting the eye or the surrounding adnexa. Some of the general documentation requirements are discussed here, but greater detail for some of the more common diseases of the eye and adnexa will be provided in the next section.

In general, basic medical record documentation requirements include the severity or status of the disease (e.g., acute or chronic), as well as the site, etiology, and any secondary disease process. The provider’s confirmation of any diagnosis found in laboratory or other diagnostic test reports must be documented for code assignment. Provider documentation should clearly specify any cause-and-effect relationship between medical treatment and an eye disorder. Documentation in the medical record should specify whether a complication occurred intraoperatively or postoperatively, such as intraoperative versus postoperative hemorrhage.

ICD-10-CM has included specificity regarding the type and cause of eye disorders which must be documented in the medical record. Many codes also require more specific documentation of the site such as upper or lower eyelid and laterality (right, left, bilateral).

In addition to these general documentation requirements, there are specific diseases and disorders that require greater detail in documentation to ensure optimal code assignment.

Code-Specific Documentation Requirements

In this section code categories, subcategories, and subclassifications for some of the more frequently reported diseases of the eye and adnexa are reviewed. The focus is on conditions with additional and more specific clinical documentation requirements. Although not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of additional documentation needed for diseases of the eye and adnexa. The section is organized by the code category, subcategory, or subclassification depending on whether the documentation affects only a single code or an entire subcategory or category.

Conjunctivitis

Conjunctivitis is inflammation of the conjunctiva, which is the thin, clear membrane lining the inner surface of the eyelid and the outer surface of the eye. Inflammation may be caused by bacteria, viruses, allergens, or chemicals. Chronic allergic conjunctivitis is a prolonged allergic reaction to an allergen.

Giant papillary conjunctivitis is one of the most common complications of wearing contact lenses and has its own specific code. In giant papillary conjunctivitis, the inner surface of the eyelids becomes irritated and inflamed, and large bumps or papillae occur on the underside of the eyelid. The inflammation of the palpebral conjunctiva in giant papillary conjunctivitis results from repeated contact with and irritation of the conjunctiva, or as an allergic reaction to protein deposits on the surface of the contact lens.

Giant papillary conjunctivitis is not a true allergic reaction but rather is usually associated with hypersensitivity reactions. Hay fever or other associated allergies may play a role in the onset and the severity of the signs and symptoms, so provider documentation of any associated allergy is essential for accurate code assignment. As with other allergic diseases, a chronic condition can also develop and may be associated with an increased risk for the development of cataracts and glaucoma. Clear, complete documentation of the patient’s condition is needed in order to assign the most accurate diagnosis code.

The signs and symptoms of giant papillary conjunctivitis include discomfort and a reduced tolerance to contact lens wear, conjunctival redness and edema, itching, mucous discharge, photophobia, and may include blurred vision. A diagnosis of giant papillary conjunctivitis can usually be confirmed using slit lamp biomicroscopy after ruling out other possible causes with similar presentation, such as seasonal and perennial allergic conjunctivitis or chlamydial conjunctivitis. Other types of chronic conjunctivitis must be differentiated in the medical record documentation as well, such as chronic follicular conjunctivitis, vernal conjunctivitis, parasitic conjunctivitis, or other chronic allergic conjunctivitis.

There is a separate code used to report other chronic allergic conjunctivitis (H10.45) when there is not a more specific code for the documented type of chronic conjunctivitis.

ICD-10-CM Coding and Documentation Requirements

Identify type:

•Chronic giant papillary conjunctivitis

•Other specified chronic allergic conjunctivitis

For chronic giant papillary conjunctivitis identify laterality:

•Right eye

•Left eye

•Bilateral

•Unspecified

ICD-10-CM Code/Documentation
H10.411	Chronic giant papillary conjunctivitis, right eye
H10.412	Chronic giant papillary conjunctivitis, left eye
H10.413	Chronic giant papillary conjunctivitis, bilateral
H10.419	Chronic giant papillary conjunctivitis, unspecified

Documentation and Coding Example

Patient is a 19-year-old Caucasian female who presents to ophthalmologist with a 2-year history of itchy, burning, irritated eyes. Patient has worn contact lenses for five years and started to notice problems after one year of lens wear. She reported her symptoms numerous times to her optometrist and was told she had “dry eyes” and to use wetting drops. She saw a new optometrist 4 months ago who thought her problems were allergy related and prescribed Pataday eye drops and changed her to a daily wear contact lens. Patient attends college in another state and would not be able to follow up with her new optometrist so she was advised to see an eye doctor near her school if her symptoms did not improve in 2-3 months. Patient states she has used the Pataday drops daily and also uses Blink brand lubrication drops during the day and Sustane brand at night. She is unable to tolerate contact lenses for more than 2-3 hours and has rarely worn them in the past 3 months. On examination, this is an attractive, articulate young woman who has applied light makeup to enhance her face and eyes. She does admit to not being fastidious about removing her makeup every night. She states she does have seasonal allergies treated with Claritin and she takes vitamins and Chinese herbs prescribed by her acupuncturist. On examination, there is no evidence of blepharitis, conjunctival redness or inflammation. Corneas of both eyes are mildly pitted. Inverting the lid to look at the inner surface of her eyelids is extremely painful but even a quick look confirms that the surface is rough and red with raised papillae on both the upper and lower lids bilaterally. She is prescribed Lotemax Eye drops BID x 6 weeks and is to add Restasis eye drops BID beginning 2 weeks after starting the Lotemax. Patient is advised to refrain from contact lens use as much as possible. RTC in 3 months. She is advised to return sooner if her symptoms worsen or have not improved in 3-4 weeks.

Diagnosis: Chronic giant papillary conjunctivitis secondary to contact lens use.

ICD-10-CM Diagnosis Code(s)

H10.413

Chronic giant papillary conjunctivitis, bilateral

Coding Note(s)

There are several subcategory codes for different types of chronic conjunctivitis, in addition to the codes for chronic giant papillary conjunctivitis that also identify the affected eye.

Cataract

A senile cataract, now more commonly referred to as age-related cataract, is a disorder of the lens of the eye characterized by gradual, progressive thickening of the lens which becomes cloudy and eventually leads to vision impairment. Other forms of cataract exist including those that affect infants and children, those caused by trauma, drug-induced cataracts, and cataracts caused by underlying disease of the eye so careful review of the medical record documentation is required to ensure that the most appropriate code is selected.

The term age-related cataract has replaced senile cataract, and age-related cataracts are classified in category H25 and the condition is further differentiated by other characteristics of the cataract. For example, there are specific codes for the most common types of senile cataracts which include nuclear cataract, cortical cataract, and posterior subcapsular cataract as well as for less common types. As with all paired organs, cataract codes include laterality and must be specified as right, left, or bilateral. Additionally, there have been some terminology changes. For example, the term hypermature cataract has been replaced with the term morgagnian-type cataract which is classified in subcategory H25.2. Furthermore, some conditions that previously had a specific code are now reported using code H25.89 Other age-related cataract. For example, there is no longer a specific code for total or mature cataract, so in the absence of other more specific documentation code H25.89 is assigned.

Coding and Documentation Requirements

Identify type of age-related cataract:

•Combined forms

•Incipient

–Anterior subcapsular polar

–Cortical

–Posterior subcapsular polar

–Other incipient type

•Morgagnian type

•Nuclear

•Other specified type

•Unspecified type

Identify laterality:

•Right

•Left

•Bilateral

•Unspecified

ICD-10-CM Code/Documentation
H25.011	Cortical age-related cataract, right eye
H25.012	Cortical age-related cataract, left eye
H25.013	Cortical age-related cataract, bilateral
H25.019	Cortical age-related cataract, unspecified
H25.031	Anterior subcapsular polar age-related cataract, right eye
H25.032	Anterior subcapsular polar age-related cataract, left eye
H25.033	Anterior subcapsular polar age-related cataract, bilateral
H25.039	Anterior subcapsular polar age-related cataract, unspecified
H25.041	Posterior subcapsular polar age-related cataract, right eye
H25.042	Posterior subcapsular polar age-related cataract, left eye
H25.043	Posterior subcapsular polar age-related cataract, bilateral
H25.049	Posterior subcapsular polar age-related cataract, unspecified

Documentation and Coding Example

Seventy-three-year-old Caucasian female presents for eye exam after noticing some loss of sharpness in her distance vision. She states the change in distance vision is mild but she is concerned about it. She does not drive or watch TV, but she does knit and read and these activities have not been impaired. On examination, this is a very petite, athletic appearing septuagenarian. She states she always keeps her skin covered and wears a brimmed hat while out of doors but has never worn sunglasses. Conjunctiva are clear, without redness or excess tearing. PERRLA. Cranial nerves are grossly intact, eye muscle movement is normal. There are no areas of scotoma. Color vision intact. Autorefraction of distance vision showed 20/40 OD and 20/50 OS. Acuity tested manually confirms these results and with refraction she is easily corrected to 20/15 OU. Near vision is excellent without evidence of astigmatism. Proparacaine eye gtts instilled and tonometry shows OD pressure of 13 mm Hg and OS pressure of 15 mm Hg. Mydriacyl 1% gtts instilled and slit lamp exam shows normal optic nerve and macula OU and nuclear cataracts bilaterally. The cataract OD is a LOC III NO2/NC2 and the cataract OS is slightly more opaque at a LOC III NO3/NC3.

Impression: Bilateral nuclear cataracts in early stages.

Plan: Dispense glasses to correct myopia. She is advised to wear sunglasses when out of doors. Follow up in 3 months. If changes are minimal she can be followed at 6-month intervals. Her diet was reviewed and she eats ample fresh fruits and vegetables, no processed foods, and healthy fats and protein sources. She is advised she can take a supplemental multivitamin/mineral if she wishes and that she should look for one that contains Lutein, Zeaxanthin and Omega-3 FA.

ICD-10-CM Diagnosis Code(s)

H25.13	Age-related nuclear cataract, bilateral
H52.13	Myopia, bilateral

Coding Note(s)

The outdated terminology of ‘nuclear sclerosis’ has been updated in ICD-10-CM, where the same condition is now classified as ‘age-related nuclear cataract.’ ICD-10-CM also captures laterality with specific codes for left, right, and bilateral cataracts.

Choroidal Degeneration/Dystrophies

The choroid is a tissue layer made up of blood vessels and connective tissue located between the sclera and retina. It supplies nutrients to the inner parts of the eye. Choroidal degeneration refers to disorders that present with progressive loss of cellular or tissue function resulting in structural changes in the choroid. Choroidal degeneration can occur as part of age-related macular degeneration. Provider documentation of any associated disease process is needed for optimal code assignment.

Careful review of the documentation is necessary when coding choroidal degeneration, atrophy, or dystrophy. Atrophy refers to the anatomic changes from the loss of cells and tissue due to cell death, and dystrophy refers to acquired cell or tissue degeneration as a result of a genetic defect or mutation. Previously there was a specific code for dystrophies primarily involving Bruch’s membrane of the eye and specific codes for choroidal degeneration (sclerosis) unspecified, senile atrophy of the choroid, diffuse secondary atrophy of the choroid, and angioid streaks of the choroid. There is no longer a specific code for dystrophies involving Bruch’s membrane. This condition is reported with the same codes as those for unspecified choroidal degeneration (H31.10-), age-related choroidal atrophy (H31.11-), or diffuse secondary atrophy of the choroid (H31.12-) depending on the physician’s documentation.

Angioid streaks of choroid are no longer classified with codes for choroidal degenerations. This condition has been moved to subcategory H35.3 Degeneration of macula and posterior pole and is reported with code H35.33 Angioid streaks of macula. Laterality is not a component of the classification of angioid streaks of the macula so there is only a single code to report this condition.

It should also be noted that disease terminology has been updated to reflect current medical knowledge. For example, senile choroidal atrophy is the same as age-related choroidal atrophy. The Alphabetic Index entry for Atrophy, choroid, senile will direct the coder to age-related choroidal atrophy.

Coding and Documentation Requirements

Identify condition:

•Choroidal degeneration (sclerosis) or atrophy

–Age-related choroidal atrophy

–Diffuse secondary atrophy of choroid

–Unspecified choroidal degeneration

•Angioid streaks of macula (choroid)

Identify laterality for choroidal degeneration/atrophy:

•Right eye

•Left eye

•Bilateral

•Unspecified

ICD-10-CM Code/Documentation
Choroidal
Degeneration unspecified		Age-related atrophy		Diffuse secondary atrophy
H31.101	right eye	H31.111	right eye	H31.121	right eye
H31.102	left eye	H31.112	left eye	H31.122	left eye
H31.103	bilateral	H31.113	bilateral	H31.123	bilateral
H31.109	unspecified	H31.119	unspecified	H31.129	unspecified

Documentation and Coding Example

Seventy-nine-year-old Caucasian female presents to Ophthalmology clinic with her caregiver for continued monitoring of eye disease. Patient is well known to this practice, having been treated for senile degenerative choroidal atrophy and retinal neovascularization in both eyes for many years. She is a well-respected artist and a valued philanthropist in the community. She walks into the examination room on the arm of her caregiver but once settled into the chair she appears quite at ease and in control of her surroundings. Visual field acuity is significant for loss centrally in both eyes but she has fairly wide peripheral fields bilaterally. Intraocular pressure is normal in both eyes. She has been previously treated with intravitreal injections of Avastin and that seems to have controlled neovascularization in her retinas. Today we perform rapid sequence fluorescein angiography and optical coherence tomography. Both tests show hyperfluorescence dye leakage from retinal neovascularization but her disease appears stable at the present time. RTC in 3 months for recheck.

Diagnosis: Bilateral age-related degenerative choroidal atrophy and retinal neovascularization.

ICD-10-CM Diagnosis Code(s)

H31.113	Age-related choroidal atrophy, bilateral
H35.053	Retinal neovascularization, unspecified, bilateral

Coding Note(s)

In the Alphabetic Index, under the main term Atrophy, and subterms choroid and senile, the coder is referred to code H31.11-Age-related choroidal atrophy. An additional code is reported for retinal neovascularization because it is not an inherent part of the disease process for age-related choroidal atrophy.

Glaucoma

Glaucoma is a group of eye disorders characterized by elevated intraocular pressure that can cause optic nerve damage. There are a number of different types of glaucoma. The most common is a chronic condition called open angle glaucoma that develops painlessly over time. Another type, acute angle closure glaucoma, is a painful condition that develops quickly and must be treated emergently if vision is to be spared in one or both eyes. Congenital glaucoma is a type that is present at birth and usually results from abnormal eye development. Secondary glaucoma is caused by another condition such as trauma, eye disease, systemic illness, or as a side effect of medications, such as corticosteroids.

There is a great deal of variability in the care and resource utilization among glaucoma patients, so diagnosis codes that reflect disease severity allow for better management and treatment outcomes. Increased specificity of glaucoma codes was integrated to identify the stages of glaucoma. Codes reflect staging of glaucoma into mild, moderate, and severe disease based on the provider’s documentation of the visual field in the patient’s worse eye. There are also codes for indeterminate stage glaucoma and unspecified glaucoma stage. In order to code the patient’s condition to the highest level of specificity, both the specific type and stage of glaucoma must be documented.

Glaucoma codes are located in two categories. Category H40 Glaucoma is specific to type, laterality, and stage. A 7th character is appended to capture the stage. The available 7th characters for reporting the stage are as follows:

0 – Stage unspecified

1 – Mild stage

2 – Moderate stage

3 – Severe stage

4 – Indeterminate stage

Three-character category code H42 is used for Glaucoma in diseases classified elsewhere, has no additional qualifiers, and is reported secondary to the underlying condition, such as amyloidosis, aniridia, Lowe’s syndrome, Rieger’s anomaly, or other specified metabolic disorder.

ICD-10-CM Coding and Documentation Requirements

Identify type:

•Glaucoma in diseases classified elsewhere

–Code first underlying condition such as:

»amyloidosis (E85.-)

»aniridia (Q13.1)

»glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39)

»Lowe’s syndrome (E72.03)

»Rieger’s anomaly (Q13.81)

»specified metabolic disorder (E70-E88)

•Glaucoma suspect

–Anatomical narrow angle (primary angle closure suspect)

–Open angle with borderline findings

»High risk

»Low risk

◦Ocular hypertension

◦Preglaucoma

◦Primary angle closure without glaucoma damage

◦Steroid responder

•Open-angle glaucoma

–Capsular glaucoma with pseudoexfoliation of lens

–Chronic simple glaucoma

–Low-tension glaucoma

–Pigmentary glaucoma

–Primary open-angle glaucoma

–Residual stage of open-angle glaucoma

–Unspecified open angle glaucoma

•Primary angle-closure glaucoma

–Acute angle-closure glaucoma (attack) (crisis)

–Chronic (primary) angle-closure glaucoma

–Intermittent angle-closure glaucoma

–Residual stage of angle-closure glaucoma

–Unspecified

•Secondary glaucoma (due to)

–Drugs

–Eye inflammation

–Eye trauma

–Other eye disorders

•Other specified type of glaucoma

–Aqueous misdirection (malignant glaucoma)

–Hypersecretion glaucoma

–With increased episcleral venous pressure

–Other specified type

•Unspecified type

Identify laterality:

•Right eye

•Left eye

•Bilateral

•Unspecified

Identify stage using the appropriate 7th character:

0 – Stage unspecified

1 – Mild stage

2 – Moderate stage

3 – Severe stage

4 – Indeterminate stage

Note: Stage is not required for conditions listed under glaucoma suspect, residual stage, acute or intermittent angle-closure glaucoma, other specified types of glaucoma (aqueous misdirection, hypersecretion, glaucoma with increased episcleral venous pressure), unspecified glaucoma, or glaucoma in diseases classified elsewhere.

Use an additional code for adverse effect, if applicable, to identify the drug (T36-T50 with fifth or sixth character 5) in cases of glaucoma secondary to drugs.

Code also the underlying condition for glaucoma secondary to eye trauma, eye inflammation, and other eye disorders.

ICD-10-CM Code/Documentation
A 7^th character is required to identify the stage on the glaucoma codes listed below:
H40.111	Primary open-angle glaucoma, right eye
H40.112	Primary open-angle glaucoma, left eye
H40.113	Primary open-angle glaucoma, bilateral
H40.119	Primary open-angle glaucoma, unspecified
H40.211	Acute angle-closure glaucoma, right eye
H40.212	Acute angle-closure glaucoma, left eye
H40.213	Acute angle-closure glaucoma, bilateral
H40.219	Acute angle-closure glaucoma, unspecified

Documentation and Coding Example

Patient is a 45-year-old African-American male who presents to the office today for ongoing care of glaucoma. This gentleman was diagnosed two years ago with angle-closure glaucoma bilaterally. Eye pressure was initially difficult to control and his left eye progressed fairly rapidly to moderate disease. Clinically, the stage of disease in his right eye was difficult to determine, however both eyes appeared to be stabilized at his exam six months ago using Cosopt eye drops bilaterally BID. Patient states he is having no side effects from the medication. On examination, his visual field perception is unchanged in both eyes with only minimal visual loss in the outer periphery of the right but circumferential in the left. Visual acuity is also unchanged on the right at 20/100 but slightly improved on the left at 20/200. His current glasses prescription for distance and reading is working fine for him. Right eye pressure is 22 mmHG, left is 23 mmHG. Slit lamp exam shows no unusual tissue growth and smooth conjunctiva and corneas bilaterally. Gonioscopy exam shows adequate fluid drainage in both eyes. Scanning laser polarimetry and optical coherence tomography is performed and compared to previous studies. Disease is stable at this time. Treatment options discussed with patient. He is not experiencing any side effects from the medication and he has good insurance coverage so it is not a financial burden to obtain the prescriptions each month. Patient has some anxiety about surgery on his eyes and as long as the medication is working, he prefers not to do any other type of treatment at this time. RTC in 6 months, sooner if symptoms arise.

Diagnosis: Bilateral chronic angle-closure glaucoma.

ICD-10-CM Diagnosis Code(s)

H40.2222	Chronic angle-closure glaucoma, left eye, moderate stage
H40.2214	Chronic angle-closure glaucoma, right eye, indeterminate stage

Coding Note(s)

When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. The seventh code character “2” is assigned to identify moderate stage glaucoma in the left eye and the seventh character “4” is assigned to the glaucoma code for the right eye because the stage cannot be clinically determined. The seventh character “4” is used for glaucomas whose stage cannot be clinically determined, and should not be confused with the seventh character “0”, unspecified, which should be assigned when there is no documentation regarding the stage of the glaucoma.

Pterygium

A pterygium is a benign growth or thickening of the conjunctiva that grows onto the cornea. As it grows, the pterygium may become red and irritated and may cause visual disturbances. Pterygium is typically associated with ultraviolet light exposure but chronic conjunctival inflammation can cause localized amyloidosis.

There are a number of specific types of pterygiums identified in ICD-10-CM including a subcategory for amyloid pterygium (H11.01) which previously was reported with an unspecified code. Amyloid is a protein that gets deposited in the body organs and tissues where it may accumulate as in amyloid deposits on the conjunctiva.

ICD-10-CM Coding and Documentation Requirements

Identify type:

•Amyloid pterygium

–Central pterygium

–Double pterygium

–Peripheral pterygium

»Progressive

»Stationary

–Recurrent

•Unspecified pterygium

Identify laterality:

•Right eye

•Left eye

•Bilateral

•Unspecified

ICD-10-CM Code/Documentation
H11.001	Unspecified pterygium of right eye
H11.002	Unspecified pterygium of left eye
H11.003	Unspecified pterygium of eye, bilateral
H11.009	Unspecified pterygium of eye, unspecified
H11.011	Amyloid pterygium of right eye
H11.012	Amyloid pterygium of left eye
H11.013	Amyloid pterygium of eye, bilateral
H11.019	Amyloid pterygium of eye, unspecified
H11.021	Central pterygium of right eye
H11.022	Central pterygium of left eye
H11.023	Central pterygium of eye, bilateral
H11.029	Central pterygium of unspecified eye
H11.031	Double pterygium of right eye
H11.032	Double pterygium of left eye
H11.033	Double pterygium of eye, bilateral
H11.039	Double pterygium of unspecified eye
H11.041	Peripheral pterygium, stationary, of right eye
H11.042	Peripheral pterygium, stationary, of left eye
H11.043	Peripheral pterygium, stationary, of eye, bilateral
H11.049	Peripheral pterygium, stationary, of unspecified eye
H11.051	Peripheral pterygium, progressive, of right eye
H11.052	Peripheral pterygium, progressive, of left eye
H11.053	Peripheral pterygium, progressive, of eye, bilateral
H11.059	Peripheral pterygium, progressive, of unspecified eye
H11.061	Recurrent pterygium of right eye
H11.062	Recurrent pterygium of left eye
H11.063	Recurrent pterygium of eye, bilateral
H11.069	Recurrent pterygium of unspecified eye

Documentation and Coding Example

This 34-year-old Caucasian male is self-referred to Ophthalmology with concerns about excessive tearing and patchy white growths in his eyes with occasional blurred vision in the left eye. Patient teaches physical education at the local high school and is an avid outdoorsman. He snowboards in winter, plays golf at least 9 months of the year, enjoys water sports on the local lake in the summer. He always wears sunglasses and/or a hat outside. He denies eye pain other than mild irritation relieved by OTC eye drops. On examination, visual acuity is 20/20, near and far. The eyes bilaterally have mild redness of the conjunctiva with no evidence of blepharitis. A small white patch is noted in the upper inner edge of the right cornea and a larger patch in the lower outer edge of the left cornea. Slit lamp exam confirms that they are located right on the edge of the cornea, slightly raised and contain a network of small blood vessels. The characteristics are typical of amyloid pterygium. Lesion on right eye is approximately 3mm x 4 mm and left eye measures 7mm x 9 mm. Corneal topography and photography is performed to document size and shape. Patient is counseled that these are usually benign growths but it would be wise to remove the lesion on the left because it is starting to affect vision. Patient is in agreement with that plan and is referred for surgical consultation.

Diagnosis:

Amyloid pterygium, right eye, 3mm x 4 mm.

Amyloid pterygium left eye, 7mm x 9 mm.

ICD-10-CM Diagnosis Code(s)

H11.013

Amyloid pterygium of eye, bilateral

Coding Note(s)

ICD-10-CM includes specific subcategories for the different types of pterygium, including amyloid pterygium. These codes further specify the affected eye as right, left, or bilateral.

Summary

Best practices in documentation of disorders of the eye and adnexa require more detailed information on the diagnosis and treatment of these conditions. In addition to general documentation requirements such as the severity or status of the disease, the affected site, the etiology, and any secondary disease process, there are specific diseases and disorders that require greater detail in medical record documentation to ensure optimal code assignment.

ICD-10-CM includes specificity regarding the type and the cause of eye disorders which must be documented in the medical record. Many codes require specific documentation of the site including right, left, or bilateral and upper or lower eyelid.

Understanding new, updated, and more specific coding terminology will be needed in addition to more detailed documentation of the patient’s condition. Some aspects of coding diseases of the eye and adnexa are improved in ICD-10-CM with the addition of a number of combination codes that identify both the disorder and the common manifestation.

Resources

Documentation checklists are available in Appendix A for the following condition(s):

•Cataract

•Conjunctivitis

•Glaucoma

Chapter 7 Quiz

1.Where are the combination codes for diabetes mellitus with eye conditions classified in ICD-10-CM?

a.Chapter 1 - Certain infectious and parasitic diseases (A00-B99)

b.Chapter 4 - Endocrine, nutritional and metabolic diseases (E00-E89)

c.Chapter 7 - Diseases of the Eye and Adnexa (H00-H59)

d.Chapter 18 - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

2.Which of the following disorders of the eye and adnexa are NOT classified in ICD-10-CM Chapter 7 Diseases of the Eye and Adnexa (H00-H59)?

a.Conditions associated with a neoplastic process

b.Complications of pregnancy, childbirth and the puerperium

c.Conditions resulting from injury or trauma to the eye and orbit

d.All of the above

3.Which of the following statements is true regarding coding of glaucoma?

a.Dual codes are required to report the type and stage of glaucoma

b.A combination code can be used to report the type and stage of glaucoma

c.Laterality needs to be documented in the medical record

d.Both B and D

4.How is a diagnosis of senile choroidal atrophy classified in?

a.Age-related choroidal atrophy

b.Choroidal degeneration or sclerosis

c.Diffuse secondary atrophy of choroid

d.All of the above

5.How are postprocedural complications of eye and adnexa classified?

a.In Chapter 19 Injury, poisoning and certain other consequences of external causes (S00-T88)

b.In Chapter 20 External causes of morbidity (V00-Y99)

c.In Chapter 21 Factors influencing health status and contact with health services

d.In Chapter 7 in a separate code block at the end of the chapter

6.The physician documents the patient’s diagnosis as bilateral glaucoma but there is no documentation regarding determination of the stage of the glaucoma. What 7th character glaucoma stage is assigned in this case?

a.0

b.1

c.4

d.None, the provider must be queried for documentation of the glaucoma stage

7.The physician documents bilateral glaucoma and documents each eye as having a different type or stage. How is this coded?

a.One code is assigned for each type of glaucoma but only the 7th character for the highest glaucoma stage is assigned.

b.The code for each eye is assigned for each type of glaucoma with the appropriate 7th character for the stage.

c.The code for bilateral glaucoma is assigned with the 7th character for the highest glaucoma stage

d.The code for bilateral glaucoma is assigned twice with the 7th character for Residual stage glaucoma

8.How is glaucoma associated with ocular trauma coded?

a.With a code from Chapter 7 Diseases of the eye and adnexa (H00-H59)

b.With a code from Chapter 19 Injury, poisoning and certain other consequences of external causes (S00-T88)

c.With a code from Chapter 20 External causes of morbidity (V00-Y99)

d.With a code from Chapter 21 Factors influencing health status and contact with health services

9.A patient was admitted with moderate stage glaucoma but during the admission, the stage progresses to severe glaucoma. What is the principal diagnosis?

a.The code for the stage documented on discharge

b.The code for the stage documented on admission

c.The code for the highest glaucoma stage is documented

d.The code for the indeterminate stage

10.The physician has documented that the patient has bilateral choroidal degeneration due to Bruch’s membrane dystrophy. How is this coded?

a.There are no codes for choroidal degeneration due to Bruch’s membrane dystrophy so the physician must be queried.

b.With code H31.8 Other specified disorders of the choroid

c.With code H31.103 Choroidal degeneration, unspecified, bilateral

d.With code H31.123 Diffuse secondary atrophy of choroid, bilateral

Chapter 7 Answers and Rationales

1.Where are the combination codes for diabetes mellitus with eye conditions classified in ICD-10-CM?

b.Chapter 4 - Endocrine, nutritional and metabolic diseases (E00-E89)

Rationale: According to the Excludes2 note at the beginning of Chapter 7 of ICD-10-CM, diabetes mellitus related eye conditions are coded to E08.3-, E09.3-, E10.3-, E11.3-, and E13.3-, classified in Chapter 4.

2.Which of the following disorders of the eye and adnexa are NOT classified in ICD-10-CM Chapter 7 Diseases of the Eye and Adnexa (H00-H59)?

d.All of the above

Rationale: All of the listed conditions are included in the list of excluded conditions at the beginning of Chapter 7.

3.Which of the following statements is true regarding coding of glaucoma?

d.Both B and D

Rationale: ICD-10-CM Tabular List includes combination codes that identify the type, stage and laterality of glaucoma. The ICD-10-CM guidelines for coding glaucoma provide additional direction.

4.How is a diagnosis of senile choroidal atrophy classified?

a.Age-related choroidal atrophy

Rationale: The Index entry for atrophy of the choroid, senile directs the coder to age-related choroidal atrophy.

5.How are postprocedural complications of eye and adnexa classified?

d.In Chapter 7 in a separate code block at the end of the chapter

Rationale: ICD-10-CM has a separate code block at the end of Chapter 7 (H59) to classify all intraoperative and postprocedural complications from treatment of eye and adnexa disorders together.

a.0

Rationale: The glaucoma codes in the Tabular List of ICD-10-CM include an instructional note directing the user to assign one of the listed 7th characters to the code to designate the stage of glaucoma. According to the ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.7.a.5 the seventh character “0”, unspecified, should be assigned when there is no documentation regarding the stage of the glaucoma.

7.The physician documents bilateral glaucoma and documents each eye as having a different type or stage. How is this coded?

b.The code for each eye is assigned for each type of glaucoma with the appropriate 7th character for the stage.

Rationale: According to the ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.7.a.3, assign a code for the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye.

8.How is glaucoma associated with ocular trauma coded?

a.With a code from Chapter 7 Diseases of the eye and adnexa (H00-H59)

Rationale: In ICD-10-CM, glaucoma secondary to eye trauma is coded to H40.30-H40.33 based on the affected eye(s) with a 7th character of 0-4 to identify the glaucoma stage. An additional code is assigned also to identify the underlying condition.

9.A patient was admitted with moderate stage glaucoma but during the admission, the stage progresses to severe glaucoma. What is the principal diagnosis?

c.The code for the highest glaucoma stage is documented

Rationale: According to Section I.C.7.a.4 of the ICD-10-CM Official Guidelines for Coding and Reporting, when a patient is admitted with glaucoma and the stage evolves during the admission, assign the code for highest stage documented.

10.The physician has documented that the patient has bilateral choroidal degeneration due to Bruch’s membrane dystrophy. How is this coded?

c.With code H31.103 Choroidal degeneration, unspecified, bilateral

Rationale: There is no entry in the alphabetic index for Dystrophy, Bruch’s membrane. However, the physician has specified that the patient has choroidal degeneration due to Bruch’s dystrophy. Searching the Alphabetic Index under the entry Degeneration, Bruch’s membrane, the instruction is given to see degeneration, choroid and when that term is located, the code provided is H31.10-. The 6th character 3 is added to identify the condition as bilateral.