ICD-10 Coding for Contact Lens Problems. The EyeCodingForum.com

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1 ICD-10 Coding for Contact Lens Problems The EyeCodingForum.com Jeffrey Restuccio, CPC, CPC-H, MBA Memphis TN (901) EyeCodingForum.com 1

2 Coding for Contact Lens Complications Many common conditions/diseases are not listed in the current ICD-9 manual. How will they translate to ICD-10? Will it correct all the omissions and incorrect descriptions currently found in ICD-9? For the most part, no. Yes, Dry Eye Syndrome will now be part of the ICD-10 code description. H Dry eye syndrome of right lacrimal gland But many will continue to retain international descriptions that are different from common terms used in the United States. EyeCodingForum.com 2

3 Top Five Contact Code Problem ICD-9 ICD-9 and Description Codes/Conditions ICD-9 Description Blurred Vision Eye Pain Redness of Eyes Dry Eyes Double Vision/diplopia This list includes about 80% of visits for contact lens-related problems. EyeCodingForum.com 3

4 ICD-10 Crosswalk Note separate diplopia and double vision codes. Other specified disorders of eye and adnexa [blurred 1) H57.8 vision crosswalk] 2) H57.13 Ocular pain, bilateral [four codes] 3) H57.8 Other specified disorders of eye and adnexa [redness] 4) H Dry eye syndrome of right lacrimal gland [four codes] 5) H53.2 Diplopia [ICD-9 crosswalk to 368.2] H53.19 Other subjective visual disturbances [Includes: Double vision; ICD-9 crosswalk: ] : Subjective visual disturbances: other visual distortions and entoptic (visual effects whose source is within the eye itself) phenomena EyeCodingForum.com 4

5 Common Coding Errors Corneal Disorder due to Contact Lens Corneal Edema due to Wearing of Contact Lens [this is an error per ICD-9] The two codes are recommended above but is clearly incorrect per ICD-9 guidelines Corneal pigmentations and deposits: other deposits associated with metabolic disorders [actual ICD-9 description] Other corneal disorders: corneal disorder due to contact lens Excludes corneal edema due to contact lens (371.24) EyeCodingForum.com 5

6 Correct Contact ICD-10 Codes Correct ICD-9 code H Corneal edema: corneal edema due to wearing of contact lenses Corneal edema secondary to contact lens, unspecified eye Corneal Disorder due to Contact Lens H Corneal disorder due to contact lens, unspecified eye EyeCodingForum.com 6

7 Other conditions How does one code for: more serious conditions like corneal hypoxia, infiltrates, and microbial keratitis? EyeCodingForum.com 7

8 Terms and definitions SEAL: Superior Epithelial Arcuate Lesion: It is a white lesion in the superior cornea that can be up to 0.5 mm wide and from 1 mm to 5 mm long. CLARE: Contact Lens-induced Acute Red Eye: A sudden onset of a corneal infiltrative event observed during extended wear of hydrogel contact lenses that is always associated with sleep. Patients report waking up with irritation or pain, redness and watery eyes. Sometimes, these symptoms are not noticed until soon after waking (HPI: timing). CLPU: Contact Lens-induced Peripheral Ulcer: A circular, wellcircumscribed, dense, yellowish-white, focal corneal infiltrate (0.2 mm to 2.0 mm in diameter) located in the peripheral to midperipheral cornea. It is always located in the anterior stroma and has a complete loss of overlying epithelium. Symptoms can vary but may include pain or soreness, irritation and watering. EyeCodingForum.com 8

9 Terms and definitions Microcysts: Small (15 μm to 50 μm), irregularly shaped inclusions, typically found in the paracentral to mid-peripheral zones of the cornea, best observed with retro-illumination. These show reversed illumination due to a suspected higher refractive index than the surrounding tissue. Often clear and asymptomatic. Report the underlying symptoms: EyeCodingForum.com 9

10 Terms and definitions MK Microbial Keratitis: occurs as a result of an infection of the cornea by replicating microbes (bacterial, viral, fungal or amoebae). In contact lens wear, it is usually preceded by hypoxia and/or an epithelial break. Contact lens wearers, in particularly extended wear, are more prone to develop MK. The most common bacteria associated with contact lensrelated MK is Pseudomonas aeruginosa. Bacteria tend to bind to the back surface of silicone hydrogel lenses after patients have been swimming. Always recommend that patients remove and disinfect their lenses after any exposure to pools, lakes or rivers. EyeCodingForum.com 10

11 Top MK Symptoms ICD-9 Codes Top codes Corneal Ulcer, Central Secondary Iridocyclitis, Infectious Unspecified disorder of eye and adnexa: pain in or around eye [eye pain] Other specified disorders of eye and adnexa [ redness of Eyes] Epiphora Photophobia EyeCodingForum.com 11

12 Top MK Symptoms ICD-9 Codes ICD-10 crosswalk. Not always exact. 1 H Corneal Ulcer, Central 2 Secondary Iridocyclitis, Infectious Secondary infectious iridocyclitis, right eye [also noninfectious, H20.041] H H57.13 Ocular pain, bilateral 4 H57.8 Redness of Eyes [no eye code] 5 H Unspecified epiphora, right lacrimal gland H H Epiphora due to excess lacrimation, right lacrimal gland Epiphora due to insufficient drainage, right lacrimal gland EyeCodingForum.com 12

13 Top MK Symptoms ICD-9 Codes ICD-10 crosswalk. Not always exact. 6 H Photophobia Visual discomfort, right eye [Includes: Metamorphopsia; photophobia term not in H ICD-10] Only report those codes documented, relevant to this encounter, and sufficient to support medical necessity for a given procedure or office visit. EyeCodingForum.com 13

14 Other Complications Exposure keratitis is not found in the ICD-9 manual. It is listed as: exposure keratoconjunctivitis It is an incomplete closure of the eyelid causing a dry, inflamed eye Certain types of keratoconjunctivitis: exposure keratoconjunctivitis H Exposure keratoconjunctivitis, unspecified eye EyeCodingForum.com 14

15 Exposure keratoconjunctivitis All codes; Note codes are not by eyelid. H Exposure keratoconjunctivitis, right eye H Exposure keratoconjunctivitis, left eye H Exposure keratoconjunctivitis, bilateral H Exposure keratoconjunctivitis, unspecified eye EyeCodingForum.com 15

16 Keratoconjunctivis sicca Keratoconjunctivitis sicca has two options in ICD-9. The condition involves reporting biomicroscopic findings without referring to the underlying cause Diffuse diseases of connective tissue: sicca syndrome Keratoconjunctivitis sicca Sjogren's disease [Sjögren's syndrome] Certain types of keratoconjunctivitis: keratoconjunctivitis sicca, not specified as Sjogren's [dry eyes] EyeCodingForum.com 16

17 Remember, International Definitions Keratoconjunctivitis sicca (KCS), (aka keratitis sicca, xerophthalmia or dry eye syndrome, is an eye disease caused by eye dryness it is caused by either decreased tear production or increased tear-film evaporation. H H H H Keratoconjunctivitis sicca, not specified as Sjögren's, right eye Keratoconjunctivitis sicca, not specified as Sjögren's, left eye Keratoconjunctivitis sicca, not specified as Sjögren's, bilateral Keratoconjunctivitis sicca, not specified as Sjögren's, unspecified eye EyeCodingForum.com 17

18 Dry Eye Syndrome Use the following ICD-10 code for DES H Dry eye syndrome of right lacrimal gland H Dry eye syndrome of left lacrimal gland H Dry eye syndrome of bilateral lacrimal glands H Dry eye syndrome of unspecified lacrimal gland EyeCodingForum.com 18

19 Sicca Syndrome ICD-10 GEMS Crosswalk of ICD-9: Listed also as Sjögren's syndrome: a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands, which produce tears and saliva. Unless it was diagnosed separately, M35.01 would be the correct code. ICD-10 Description M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis EyeCodingForum.com 19

20 More Terms CLPC : Contact Lens-induced Papillary Conjunctivitis (Aka Giant Papillary Conjunctivitis [GPC]): Symptoms may range from mild hyperemia of the upper tarsal conjunctiva with a few, small papillae to severe hyperemia with large, raised papillae, which have a cobblestone appearance. CLPC may present as a localized or generalized response. Symptoms include itching and a stringy or ropy mucous discharge. Excessive lens movement or decentration and blurred vision may also occur. Lens material, design or fitting characteristics may need to be modified to prevent recurrence of this condition. Etiologies for CLPC include: mechanical abrasion from poor edge design and protein film abrasiveness. A code does exist, but it's not called GPC. It all depends on the etiology. Since papillae aren't follicles, we can't use the code for follicular conjunctivitis. EyeCodingForum.com 20

21 Incorrect Coding Some Eyecare coding consultants recommend code , chronic conjunctivitis, unspecified, for an allergic underlying cause. Again, there are additional codes: Chronic conjunctivitis: other chronic allergic conjunctivitis H Unspecified chronic conjunctivitis, right eye H Chronic giant papillary conjunctivitis, right eye H Simple chronic conjunctivitis, right eye H Chronic follicular conjunctivitis, right eye EyeCodingForum.com 21

22 More Dx Ulcers of the eye; note by eye. H Unspecified corneal ulcer, right eye H Central corneal ulcer, right eye H Ring corneal ulcer, right eye H Corneal ulcer with hypopyon, right eye H Marginal corneal ulcer, right eye H Mooren's corneal ulcer, right eye H Mycotic corneal ulcer, right eye H Perforated corneal ulcer, right eye EyeCodingForum.com 22

23 Other Complications More codes ICD-9 ICD-10 Description H Corneal Neovascularization H Corneal Ghost Vessels EyeCodingForum.com 23

24 Sample CMS-1500 Form Use for codes, co-management and unique situations Use forunlisted unlisted codes, co-management and unique situations Papilledema Rheumatoid arthritis V58.69 High Risk Med - Plaquenil Other adenoviral conjunctivitis 03/1/ /1/ ,3 03/1/ RT 1 24

25 Crosslinks ICD-10 codes ICD-9 ICD-10 Description H47.10 Papilledema [unspecified] V58.69 Z High Risk Med - Plaquenil M06.9 Rheumatoid arthritis B30.1 Other adenoviral conjunctivitis Is this correct? EyeCodingForum.com 25

26 Not exactly There s always more. These are the ICD-10 descriptions H47.10 Unspecified papilledema V58.69 Z Other long term (current) drug therapy M06.9 Rheumatoid arthritis, unspecified B30.1 Conjunctivitis due to adenovirus The ICD-10 codes must be reviewed individually now before the implementation date; otherwise you will be substituting old unspecific codes for new unspecific codes that may be inaccurate and cause a denial. EyeCodingForum.com 26

27 Papilledema codes More papilledema codes. H47.10 Unspecified papilledema Papilledema associated with increased intracranial H47.11 pressure H47.12 Papilledema associated with decreased ocular pressure H47.13 Papilledema associated with retinal disorder EyeCodingForum.com 27

28 Rheumatoid arthritis Rheumatoid arthritis M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site [More 6 th digit site codes] M06.80 Other specified rheumatoid arthritis, unspecified site EyeCodingForum.com 28

29 Adenovirus B30.0 Keratoconjunctivitis due to adenovirus B30.1 Conjunctivitis due to adenovirus [crosswalk] B30.2 Viral pharyngoconjunctivitis Acute epidemic hemorrhagic conjunctivitis (enteroviral) B30.3 B30.8 Other viral conjunctivitis B30.9 Viral conjunctivitis, unspecified EyeCodingForum.com 29

30 The Bottom Line While many codes have a clean crosswalk most problems are crosswalking an unspecific ICD-9 code to an unspecific ICD-10 code. The ICD-10 codes must be reviewed early to determine which are relevant and which are not. Most won t even know the correct questions to ask. I will help you ask the right questions. That is the goal of the complete ICD-10 training course and additional webinars we will be conducting throughout Many carriers will not have representatives knowledgeable about Eyecare. It will be a challenge determining which codes they require after the October implementation date. EyeCodingForum.com 30

31 Questions? If you order the complete ICD-10 training course ($225) or the $299 bundle after purchasing this 50-minute Webinar for $49, contact for a rebate code. The EyeCodingForum is your one-stop source for all ICD-10 coding updates. In addition, we will continue to have monthly webinars on coding, billing, documentation and compliance topics relevant to Eyecare (both Optometrists and Ophthalmologists). EyeCodingForum.com 31

32 Thank you for listening to the EyeCodingForum s ICD-10 Coding for Contact Lens Problems Jeffrey Restuccio, CPC, CPC-H, MBA Memphis TN (901) EyeCodingForum.com 32

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