billing & coding
Coding Average Office Visits
Establish guidelines for your practice.
coding and billing can resemble a bowl of alphabet soup. Following are common guidelines
to help put you on the right track in determining correct diagnosis codes.
Procedure codes and diagnosis codes go hand in
hand to numerically describe a patient visit and clinical outcome. Diagnosis codes
or International Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) codes help describe the presenting clinical picture and justify medical
necessity for procedures. When verifying a patient condition or symptom in the ICD-9-CM
book, refer to the alphabetic listing first and verify the code in the tabular or
numeric listing. Always code as specifically as possible, avoiding XXX.9 codes or
codes listed as unspecified.
Back to basics
One of the most basic, but often forgotten, rules
of coding is that the primary diagnosis should always represent the patient's chief
complaint or chief presenting symptom. Consider the patient who presents with distance
vision complaints, which you determine to be caused by myopia. This patient also
presents with increased intraocular pressures, asymmetric cup-to-disc ratios, and
a family history of glaucoma. Your coding should be as follows: primary diagnosis
code of 367.1 for myopia; secondary diagnosis code of 365.01, glaucoma suspect with
open angle and borderline findings. If this same patient presents and requests a
glaucoma evaluation with the same ocular findings, the primary diagnosis code would
be 365.01, glaucoma suspect, to correspond to the chief complaint.
When the exam outcome is uncertain,
probable, suspected, questionable or rule-out, and there is no existing code, code
the patient's presenting signs or symptoms. In the case of both a confirmed diagnosis
and corresponding presenting symptoms, it's not necessary to code for both, unless
the presenting symptoms are not fully explained by the diagnosis code.
Report coexisting conditions when both
require or affect the treatment. Consider a patient presenting with a peripheral
corneal ulcer and secondary anterior chamber inflammation. Coding should include
primary and secondary diagnosis codes of 370.01 for marginal corneal ulcer, and
364.04 for secondary anterior uveitis. Code chronic diseases for the duration of
If you're just getting the hang of ICD-9-CM codes,
HHS is expected to release an ICD-10 conversion in the near future. It will not
only add 5,500 new codes, but will change the entire coding reference system to
one that is alphanumeric rather than simply numeric.
codes are assigned to preventive medicine services when a patient requests an
evaluation without signs or symptoms of a more specific diagnosis code. These
are usually not reimbursable by Medicare or third party insurance plans because
they indicate the examination was done for screening purposes rather than medical
necessity. While there are many more, here are some V codes to consider:
V19.0 Family history
of blindness or visual loss
V19.1 Family history
of other eye disorder
current use of high-risk medication (plaquenil)
completed use of high-risk medication
of eyes and vision
V80.1 Special screening
V80.2 Special screening
for cataract, congenital anomaly, or senile macular
DR. MACK IS DIRECTOR
OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE
OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU.
Optometric Management, Issue: October 2005