• Savvy Coder

    10 Retina Tips for ICD-10

    By Sue Vicchrilli, COT, OCS, Director of Coding and Reimbursement, E. Joy Woodke, COE, OCS, and Rajiv Rathod, MD, MBA

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    Chapter 7 of ICD-10 focuses on diseases of the eye and adnexa. It is where you’ll find the majority of diagnosis codes needed to report disorders of the choroid and retina.

    REPORTING LATERALITY. Not all retina codes require you to report laterality. However, when they do, you must include a 1 (right eye), 2 (left), or 3 (both) as either the code’s fifth (e.g., H30.0-*) or sixth (e.g., H35.35-) character.

    Tip 1—edema. H35.81 Retinal edema has no laterality, but H35.35- Cystoid macular degeneration (edema) does: H35.351 (right), H35.352 (left), and H35.353 (both). And H59.03- Cystoid macular edema following cataract surgery also requires laterality: H59.031 (right), H59.032 (left), and H59.033 (both). When coding H59.03-, you may also submit a “status-post condition” code (these are the Z codes).

    Tip 2—AMD. There is no laterality for codes H35.31 Nonexudative age-related macular degeneration or H35.32 Exudative AMD. Or, to put it another way: Whether wet or dry, don’t specify which eye.

    Tip 3—vitreous detachment. The codes for posterior vitreous detachment (H43.81-) and floaters (H43.39-) have laterality, but the code for flashes (H53.19) does not.

    YOU MAY NEED TO BE MORE SPECIFIC. Compared with ICD-9, greater specificity may be required for ICD-10.

    Tip 4—retinal tear. Rather than submitting retinal tear, payers may require the type of “break.” For example: H33.03- Retinal detachment with giant retinal tear, H33.3-Retinal breaks without detachment, H33.30-Unspecified retinal break without detachment, H33.31-Horseshoe tear without detachment, H33.32-Round hole without detachment, and H33.33- Multiple defects without detachment.

    Tip 5—retinal detachment. The diagnosis codes for detached retinas require specificity and laterality. For example: H33.00- Unspecified retinal detachment with retinal break, H33.01Retinal detachment with single break, H33.04-Retinal detachment with retinal dialysis, H33.2- Serous retinal detachment without break, and H33.4- Traction detachment .

    Tip 6—old retinal detachments. Defying the trend to greater specificity, there are no ICD-10 codes for old retinal detachments. For example, instead of ICD-9’s 361.06 Old retinal detachment, partial, report ICD-10’s H33.8 Other retinal detachments; instead of 361.07 Old retinal detachment, total, report H33.05- Total retinal detachment.

    Tip 7—endophthalmitis. There are numerous types of endophthalmitis codes. For example: A54.39 Gonococcal, H44.00-Purulent, H44.02-Vitreous abscess (chronic), H44.12-Parasitic, and H59.4- Bleb associated

    Tip 8—retinopathy of prematurity (ROP). When the diagnosis is ROP, stage 0 (H35.11-), reporting only H35.11 will result in a claim denial. Laterality is required.

    EXCLUDES1 NOTES. Excludes1 notes flag diagnosis codes that can’t be reported in the same eye at the same time.

    Tip 9—mutually exclusive scarring. The listing for H31.01- Macula scars of posterior pole has an Excludes1 note indicating that if you report H31.01-, you can’t also report H59.8- Chorioretinal scars after surgery for detachment for the same eye on the same day.

    Tip 10—retinal breaks. The listing for H33.3- Retinal breaks without detachment has an Excludes1 note indicating that you can’t also report H35.4- Peripheral retinal degeneration without break or H59.81- Chorioretinal scars after surgery for detachment on the same day for the same eye.

    Data gathering only. As with ICD9, when coding chorioretinal disorders in diseases classified elsewhere, you first code the underlying disease—for example, congenital toxoplasmosis (P37.1), histoplasmosis (B39.-), or leprosy (A30.-). This documentation is not required for payment, but solely for data gathering purposes.


    * When a code ends in a dash (e.g., H35.35-), that indicates there are more codes in the family from which to choose (e.g., H35.351, etc.).