ICD-9 CM. ICD-9 9 CM stands for International Classification of Diseases, 9 th revision, clinical modifications

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Ophthalmology Coding

ICD

ICD--9 CM9 CM & & CPTCPT

By Alice Landry, By Alice Landry,

Registered Health Information Administrator and Registered Health Information Administrator and

Certified Procedural Coder Certified Procedural Coder

Harvey & Bernice Jones Eye Institute Harvey & Bernice Jones Eye Institute

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ICD

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9 CM stands for International Classification of

Diseases, 9

thth

_{revision, clinical modifications}

ICD

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9 CM is used for coding diagnoses and procedures

done in the hospital. Example: glaucoma, open angle

–

365.10 (diagnosis code); trabeculectomy 12.64 (hospital

procedure code). This information is then used for billing,

research and statistics.

ICD

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9

9 -

-

CM Volumes 1 & 2 refer to illnesses and injuries.

Volume 3 refers to hospital procedures.

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Most of the diagnoses used in Ophthalmology come

from the Nervous System and Sense Organs (360

-

379)

section of ICD

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9.

9. Most ICD

Most ICD

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9 codes consist of four or five digits. These

digits provide specificity.

Example:

362

362 can be expanded to

can be expanded to

362.0

362.0 Diabetic

Diabetic

Retinopathy.

The symbol next to this code alerts you to

use a fifth digit:

362.01

362.01 Background diabetic

Background diabetic

retinopathy; 362.02 Proliferative diabetic retinopathy

.

Example:

365

365 can be expanded to

can be expanded to

365.10, Open angle

glaucoma, unspecified and 365.11, Primary open angle

glaucoma.

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V

-

codes

V

-

codes are supplementary ICD

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9 codes that are used

when a person who is not currently sick comes in for a

specific purpose, such as a vaccination.

They

’

re also used when a patient with a known disease or

injury comes in for aftercare following surgery, is on high

-

-risk medication (such as Plaquenil, V58.69), etc.

risk medication (such as Plaquenil, V58.69), etc.

If a patient has a condition that may affect his/her health

status (such as being HIV positive but not having AIDS),

then a V code would be used to describe this. If a patient is

pseudophakic (V43.1) or has an ocular prosthesis (V43.0),

these V codes help to identify why the patient is being

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Sometimes ICD

-

9

9 -

-

CM requires you to use two

codes for one diagnosis: e.g. background diabetic

retinopathy. 250.50 (type II diabetes) or 250.51

(type I diabetes)

must

be assigned along with

362.01. Therefore, the code for background

diabetic retinopathy (type II diabetes) would be

250.50, 362.01. When billing, each code would

have to be entered.

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E

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Codes

E

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codes describe causes of injury, poisoning, and

other adverse effects. E

-

codes are never used as

a primary (first listed) diagnosis codes.

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CPT

CPT or Current Procedural Terminology is developed by the Americ

CPT or Current Procedural Terminology is developed by the American an Medical Association for reporting medical services.

Medical Association for reporting medical services.

CPT codes are used to identify procedures performed in the outpa

CPT codes are used to identify procedures performed in the outpatient and tient and physician settings. Most CPT codes used in Ophthalmology come f

physician settings. Most CPT codes used in Ophthalmology come from the rom the Eye and Ocular Adnexa section

Eye and Ocular Adnexa section --6509165091--68899 (e.g.YAG capsulotomy 68899 (e.g.YAG capsulotomy - -66821).

66821).

Ophthalmological services such as visual field testing come from

Ophthalmological services such as visual field testing come from the the Medicine section (e.g. fluorescein angiography

Medicine section (e.g. fluorescein angiography –– 92235) or the Radiology 92235) or the Radiology section (pachymetry

section (pachymetry –– 76514). 76514).

CPT is also used to bill for office visits and are coded either

CPT is also used to bill for office visits and are coded either by using E/M by using E/M (evaluation and management) service

(evaluation and management) service codes (99201 codes (99201 –– 99255) or eye 99255) or eye examination codes (92002

examination codes (92002 –– 92014).92014).

These E/M and eye examination codes are usually listed on an enc

These E/M and eye examination codes are usually listed on an encounter ounter form, which is used for billing purposes. The physician and/or

form, which is used for billing purposes. The physician and/or tech then tech then checks off the appropriate code that they feel best reflects the

checks off the appropriate code that they feel best reflects the amount of amount of time and effort utilized when seeing the patient.

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New and

Established

Patients

Physician Charges

Office visits are described as either new patient or established

Office visits are described as either new patient or established patient. patient. The physician will choose to mark either an evaluation and

The physician will choose to mark either an evaluation and

management (E/M) service code or an eye examination code on an management (E/M) service code or an eye examination code on an

encounter form. Eye examination codes are used only in encounter form. Eye examination codes are used only in

Ophthalmology and are found in the Medicine section of CPT, wher

Ophthalmology and are found in the Medicine section of CPT, whereas eas E/M services has its own section in the CPT book.

E/M services has its own section in the CPT book.

A new patient is described as one who has not been seen in the c

A new patient is described as one who has not been seen in the clinic linic within the last three years. Therefore, if the patient has been

within the last three years. Therefore, if the patient has been seen seen within this time period, he/she is classified as being an establ

within this time period, he/she is classified as being an established ished patient. New patient E/M codes fall within the 99201

patient. New patient E/M codes fall within the 99201 –– 99205 range. 99205 range. New patient eye examination codes are either 92002 (new,

New patient eye examination codes are either 92002 (new, intermediate) or 92004 (new, comprehensive).

intermediate) or 92004 (new, comprehensive).

Established patient E/M codes fall within the 99211

Established patient E/M codes fall within the 99211 –– 99215 range. 99215 range. Established patient eye examination codes are either 92012

Established patient eye examination codes are either 92012

(established, intermediate) or 92014 (established, comprehensive (established, intermediate) or 92014 (established, comprehensive).).

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Modifiers

Modifiers are used to provide additional information about servi

Modifiers are used to provide additional information about services ces provided to patients. Medicare and private payers need these fo provided to patients. Medicare and private payers need these for r

further specificity. further specificity.

50 Modifier

50 Modifier –– used to identify a procedure performed bilaterally.used to identify a procedure performed bilaterally. Example: A fluorescein angiogram was done on a patient: CPT Example: A fluorescein angiogram was done on a patient: CPT code 92235 would be used. If this was done to check for a condi

code 92235 would be used. If this was done to check for a condition tion involving both eyes, a modifier

involving both eyes, a modifier –– 50 would be used to identify this. 50 would be used to identify this. Therefore the code would look like this: 92235

Therefore the code would look like this: 92235--50. 50.

RT and LT modifiers: Some payers require the use of RT (right)

RT and LT modifiers: Some payers require the use of RT (right) and and LT (left) modifiers instead of

LT (left) modifiers instead of --50. If this is the case, then the codes 50. If this is the case, then the codes would look like this: 92235

would look like this: 92235-RT, 92235-RT, 92235--LT and would be submitted on LT and would be submitted on two lines on the billing form.

two lines on the billing form.

Appendix A in the back of the CPT book lists all modifiers and g

Appendix A in the back of the CPT book lists all modifiers and gives ives a description of each.

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Modifiers

Modifiers are very important because they can affect payment. Modifiers are very important because they can affect payment.

For instance,

For instance, -25 modifiers-25 modifiers are used to show private payers that a are used to show private payers that a procedure performed was separate from the usual office visit and procedure performed was separate from the usual office visit and

shouldn

shouldn’t be included in the office visit charge. Example: A patient ’t be included in the office visit charge. Example: A patient comes in with trichiasis. Eyelashes are epilated. An office vi

comes in with trichiasis. Eyelashes are epilated. An office visit sit would be charged using either an E/M or an eye examination code would be charged using either an E/M or an eye examination code

and a

and a modifier modifier --2525 attached to it to show the payer that it was attached to it to show the payer that it was separate from the visit. Then, the code for the procedure (epila

separate from the visit. Then, the code for the procedure (epilation) tion) would be coded. Example:

would be coded. Example: 9200292002--2525 (new patient eye exam), (new patient eye exam),

67820

67820 (epilation with forceps). (epilation with forceps).

TC modifiers

TC modifiers identify the technical component of a procedure. identify the technical component of a procedure. Example: A

Example: A-- scan IOL has a professional component and a scan IOL has a professional component and a technical component. If a facility provides just the technical technical component. If a facility provides just the technical

component (i.e. the administration of an A scan and the test is

component (i.e. the administration of an A scan and the test is sent sent to another physician

to another physician’’s office for him/her to read, then one would s office for him/her to read, then one would attach a modifer

attach a modifer --TCTC to the code. The physicianto the code. The physician’s office would ’s office would attach a

attach a --26 modifier26 modifier (professional component) to the code when (professional component) to the code when they charge for it.

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Consult Visits

Physicians can charge a new patient a consult visit

if the patient has been referred from a physician in

another specialty. Example: A comprehensive

ophthalmologist can refer a patient to a cornea

specialist or a retina specialist.

The E/M codes for these visits are in the range of

99241

–

99255.

99241

–

99245 are used for outpatient visits.

99251

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Documentation

Documentation is very important. One should always remember tha Documentation is very important. One should always remember that t

if it isn

if it isn’’t noted, the person reading the chart may assume it didnt noted, the person reading the chart may assume it didn’’t t happen. The way documentation is worded can also affect whether happen. The way documentation is worded can also affect whether

a claim will be paid or not. For instance, care should be taken

a claim will be paid or not. For instance, care should be taken when when noting the chief complaint or the reason a patient is being seen

noting the chief complaint or the reason a patient is being seen.. Don

Don’t write: ’t write: ““Patient presents today for annual examPatient presents today for annual exam”” if the patient is if the patient is returning for a diabetic eye evaluation or a glaucoma check.

returning for a diabetic eye evaluation or a glaucoma check. Don

Don’t write: ’t write: ““No problems, no complaintsNo problems, no complaints”” if vision is 20/80 OU due if vision is 20/80 OU due to cataracts.

to cataracts.

Not only would this not reflect the true reason the patient is b

Not only would this not reflect the true reason the patient is being eing seen, it could mean a denial of a claim.

seen, it could mean a denial of a claim.

Documentation should also reflect the reason a procedure is bein Documentation should also reflect the reason a procedure is being g

performed. performed.

Coders rely on this documentation so that they can correctly ide

Coders rely on this documentation so that they can correctly identify ntify which codes are to be used. Not only can this affect reimburseme which codes are to be used. Not only can this affect reimbursement, nt,