APR 12, 2024
When Should a Diagnosis Be Linked to an Office Visit?
A patient presented for an intraocular pressure (IOP) check for H40.31X0 glaucoma secondary to eye trauma. Although I am not performing a diabetic exam, would I still assess the patient's diabetes diagnosis and link to my office visit billing?
Answer: Link the diagnoses that are documented as assessed and treated during the visit. From the Academy’s Fundamentals of Ophthalmic Coding:
“Comorbidities and underlying disease are not considered in selecting the level of evaluation and management (E/M) unless they are addressed (i.e., evaluated or treated at the encounter) and their existence increases the amount or complexity of data to be reviewed or the risk of complications in patient management.”