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  • Savvy Coder

    What Ophthalmologists Need to Know About the ICD-10 Codes That Are New on Oct. 1, 2019

    By Sarah Cartagena, Academy Health Policy Specialist, Jennifer S. Edgar, CPC, CPCO, OCS, OCSR, Academy Manager of Coding and Reimbursement, and Sue J. Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Each year, on Oct. 1, CMS imple­ments hundreds of changes to the ICD-10 codes.

    What changed on Oct. 1. This year, there are no revisions or deletions of ophthalmic codes, but several import­ant changes do impact ophthalmology. The most important of these are listed below.

    Failed Vision Screening

    For pediatric ophthalmology and com­prehensive ophthalmology practices, there are two new long-awaited diagno­ses for failed vision screening:

    • 020 Encounter for examination of eyes and vision following failed vision screening without abnormal findings
    • 021 Encounter for examination of eyes and vision following failed vision screening with abnormal findings

    Fracture of the Orbital Roof

    Ophthalmologists who are oculofacial specialists can now code for fractures in much greater detail.

    If there is fracture of the skull and facial bones (S02), you can now indi­cate whether it involves:

    • a fracture of the orbital roof (S02.12),
    • a fracture of the medial orbital wall (S02.83), or
    • a fracture of the lateral orbital wall (S02.84).

    (Note: These codes can be used together when the patient has multiple orbital fractures.)

    Example: S02.12 Fracture of orbital roof. Additional characters are required to provide extra detail.

    Add a sixth character to indicate laterality:

    • 1 for the right eye
    • 2 for the left eye

    For instance, use S02.121 if a patient has a fractured orbital roof in the right eye.

    Next, add a seventh character to tell more of the story:

    • A for initial encounter, closed frac­ture
    • B for initial encounter, open fracture
    • D for subsequent encounter with routine healing
    • G for subsequent encounter with delayed healing
    • K for subsequent encounter for fracture with nonunion
    • S for sequela. (Note: Workers’ com­pensation recognizes sequela diagnoses codes, but many federal and commer­cial payers do not.)

    For instance, S02.121B indicates the initial encounter when the patient had an open fracture of the right eye.

    New Z Codes

    The Z codes indicate the reason for the patient encounter. They repre­sent “factors influencing health status and contact with health services.” In ophthalmology, they are rarely used as the primary diagnosis code. The Oct. 1 changes include three new Z codes that ophthalmologists might use:

    • 006 Personal history of melano­ma in-situ
    • 007 Personal history of in-situ neoplasm of skin
    • 15 Personal history of latent tuberculosis infection

    Watch for Excludes1 Edits

    Since the 2015 inception of ICD-10, an increasing number of commercial payers have started implementing Excludes1 edits.

    What is an Excludes1 edit? Excludes1 indicates that the patient can’t medically have certain combinations of diagnoses in the same eye at the same time.

    For instance, a patient can’t have a code from the H04.53 Neonatal obstruc­tion of nasolacrimal duct family as well as a code from the Q10.5 Congenital stenosis and stricture of lacrimal duct family. If both diagnoses are reported, the claim will automatically be denied. This process is similar to CCI edits, but it involves ICD-10 codes rather than CPT codes.

    Who Is Ready on Oct. 1?

    Each year, many ophthalmology practices are more prepared than their payers for the annual updates to the ICD-10 codes.

    Why payers often aren’t ready on Oct. 1. To implement ICD-10 code changes, payers must:

    • upload all the new diagnoses in their system,
    • link the diagnoses to associated CPT codes, and
    • update any payer policies, such as local coverage determinations.

    What is a local coverage determi­nation (LCD)? Each Medicare Part B payer has the discretion to establish specific coverage policies for tests and surgical procedures. When finalized, these LCDs are the rules by which you will be held accountable when you are audited. Some LCDs are accompanied by an article that includes additional information. (See “Use These ICD-10 Resources” for instructions on getting the updated LCDs.)

    What you should do. Physician practices must upload all the new codes and watch for coverage policies. You can check online to see if any LCDs have been updated by your Medicare Part B payer(s).

    If a claim is denied as “not medically necessary,” that might mean that the ICD-10 code has not yet been uploaded or assigned a CPT code by that partic­ular payer.

    Use These ICD-10 Resources

    To make sure you are up to speed on this year’s ICD-10 updates, the Amer­ican Academy of Ophthalmic Execu­tives (AAOE) has updated its ICD-10 resources, which include an ophthal­mology-specific reference book and a selection of free online resources.

    Buy the 2020 edition of ICD-10-CM for Ophthalmology: The Complete Ref­erence. The Academy’s updated guide to ICD-10 was published in September ( All new diagnoses are highlighted. There is a strikethrough for codes that are still valid but not payable (e.g., unspecified diagnoses). It also includes Excludes1 code combinations. New to ICD-10? Read the instructions for novices.

    Buy the online subscription to Oph­thalmic Coding Coach. Any CPT codes affected by ICD-10 changes have been updated.

    Save 10%. Enjoy a 10% discount when you buy four or more coding products (

    Get the AAOE’s free ICD-10 mate­rials. Visit for updated decision trees and subspecialty-specific quick reference guides.

    Get the updated LCDs. To find the LCDs that apply to you, visit and then click on the Medicare Part B payer(s) that your practice works with.

    Get coding news updates. Go to for coding updates, regulatory news, coding “top 10s,” and “Ask the Expert” responses to common—and not-so-common—coding queries.

    Tip: Use the filter if you want to find coding news updates that are specific to exams, testing, and/or a particular subspecialty.

    Got questions? When ophthalmolo­gy practices have a coding conundrum, they have several options for requesting help:

    Recently in Savvy Coder

    Catch up on this year’s coding advice.

    • E&M Code or Eye Visit Code? Nine scenarios when you should not use an Eye visit code. (September.)
    • Is the Patient New or Established? Test your knowledge. In five diverse sce­narios, which would you bill: an exam for a new patient or for an established patient? (August.)
    • Coding for Eye Injuries, Parts 1 and 2. Three case studies walk you through when to use codes 99050-99060. (June and July.)
    • 12 Best Practices for Coding, Parts 1 and 2. Despite never-ending changes to the reimbursement regulations, these 12 rules of thumb should help to ensure that your coding stays tip-top. (January and May.)
    • E&M Codes Versus Eye Visit Codes. Effective Jan. 1, 2019, changes to E&M coding requirements brought new rules for documenting office visits. (April.)
    • Code-a-Palooza: Money Talks, But Can You Make It Sing? If you’re coming to AAO 2019, you should tackle these questions from last year’s Code-a-Palooza before attending Code-a-Palooza 2019 on Sunday, Oct. 13, 4:30-5.30 p.m. (March.)
    • CPT and HCPCS Updates. New codes for electroretinography (ERG) testing, biopsies, and more. (February.)