• Commotio Retina Involving Macula - Coding for Ocular Trauma case study


    An 8-year-old nephew of retina specialist was hit in left eye with soccer ball. Immediately complained of decreased vision. Patient’s father took him to see his uncle.

    Impression: No blood in AC or vitreous, but commotio retina was present involving macula.

    Plan: Monitor patient closely and return prn or 1 week

    Medical Decision Making for E/M coding

    Number and/or complexity of problems 1 undiagnosed new problem with uncertain prognosis Moderate
    Amount and/or complexity of data Independent historian – Dad Low
    Risk of complications Low Low

    E/M code 99203/99213
    The patient is physician’s nephew.  Does this impact billing?  Physicians can’t bill for services they provide to family members. It’s okay to bill your nephew.

    CMS SMC Transmittal 2332. Family is defined as: Members of your own household

    • Domestic partners
    • Husband or wife
    • Natural or adoptive parent, child or sibling
    • Step-parent, step-child, step-brother or step-sister
    • Grandparents, grandchildren or their spouses
    • Father or mother-in-law
    • Sons or daughter-in law

    ICD-10 Selection

    • H35.81 Other specified retinal disorders; retinal edema for commotio retina.
    • W21.02XA Struck by soccer ball, initial encounter.

    The Rest of the Story
    Kyle returned to office a week later. Commotio resolved but still 20/100 acuity. Documented order for OCT placed and the imaging of the macula revealed partial thickness macular hole.

    Medical Decision Making for E/M coding

    Number and/or complexity of problems 1 acute complicated injury Moderate
    Amount and/or complexity of data Independent historian – Dad Low
    Risk of complications Low Low

    E/M code 99213

    • Plus 92134 OCT

    Kyle continued to be seen five or six visits over the next two months. Vision improved to 20/40 but still had residual effect of partial thickness hole.

    Question? Is Kyle at risk for glaucoma in the future? Yes

    ICD-10 Selection

    • H35.342 Macular cyst, hole, or pseudohole, left eye.