Each October, new and updated ICD-10 codes go into effect.
Although some practices have already begun using these codes, payers may not be as quick to update their systems. If you get a denial based on a diagnosis, ask about what the payer allows. It may be that their systems are not up to date.
For 2020, we advise practices to review the “Excludes1” edits that impact ophthalmology. The term Excludes1 means that you cannot code two diagnoses together when it is not possible for both conditions to occur together. An example would be a congenital form versus an acquired form of the same condition.
Medicare has stated that if the two diagnoses are unrelated, you can use both. But in an appeal, the burden is on the physician to provide the necessary documentation that they are indeed unrelated.
Excludes1 edits are now becoming more burdensome to practices, so be aware of what impacts your specialty.
For example, H35.2- “Other nondiabetic proliferative retinopathy” has an Excludes1 stating that proliferative vitreo-retinopathy with retinal detachment (H33.4-) should not be coded in the same session. We also see that H53.03 Strabismic amblyopia has an Excludes1 indicating that strabismus (H50.-) cannot be coded in the same session.
There are a few new ICD-10 codes that impact ophthalmology.
Failed Vision Screening
These codes are typically for pediatric ophthalmologists to use for patients referred from schools and primary care offices when they fail a vision screening:
Z01.020 Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021 Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Fractures of Orbital Roof, Medial Wall and Lateral Wall
These codes expand existing codes for fractures of the orbit, including additional character codes for indicating the location and status of fractures somewhere in the orbit.
- S02.12-- Fracture of orbital roof
- S02.83-- Fracture of medial orbital wall
- S02.84-- Fracture of lateral orbital wall
These codes will have seven characters with these characteristics:
The sixth character indicates laterality: 1 = right eye, 2 = left eye
The seventh and final character tells more about the status of the fracture:
- 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. Sequela is typically used as a secondary code to the new condition the patient has. We most often see this used in third-party liability payers like workers compensation.
Here are two examples of how the new codes would work:
- S02.831D would be used for a subsequent encounter for a right eye fracture of medial orbital wall with routine healing.
- S02.122G would be used for a subsequent encounter of the left eye orbital roof fracture with delayed healing.
Further Resources
These updates and others can be found in ICD-10-CM for 2020 and online Coding Coach effective Oct. 1.
About the author: Jennifer S. Edgar, CPC, CPCO, OCS, OCSR, is a coding specialist and manager in the Academy’s Coding and Reimbursement section. She also is a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series.