Ophthalmology Quick Reference Card

Transcription

1 Purpose: Provide guidance for documentation required to assign the most appropriate and detailed codes in the new coding system (ICD-10 CM/PCS). Laterality Status of disease Origin of disease Left Right Bilateral Acute Chronic Intermittent Recurrent Acquired Congenital Neonatal Infantile/Juvenile/of Childhood Hereditary Traumatic Educational Services/HIM 02/17/14 Page 1 of 8

2 Visual Disturbances Amblyopia Deprivation Hysterical Nocturnal Refractive Strabismic Toxic specify agent Uremic Vitamin A deficiency Subjective visual disturbances Day blindness Transient vision Sudden visual loss Visual discomfort Visual distortions of shape and size Psychological visual disturbances Other specify Visual field defects Scotoma involving central area Scotoma of blind spot area Sector or arcuate defects Other localized visual defect specify Homonymous bilateral field defects Heteronymous bilateral field defects Generalized contracture of visual field Educational Services/HIM 02/17/14 Page 2 of 8

3 Disorders of Ocular Muscles, Binocular Movement, Accommo-dation,and Refraction Strabismus Concomitant Cyclotropia Esotropia = convergent concomitant Accommodative component Monocular/Alternating Esotropia with A pattern with V pattern with other specified noncomitances intermittent alternating Exotropia = divergent concomitant Monocular/Alternating Exotropia with A pattern with V pattern with other specified noncomitances intermittent alternating Duane s syndrome Due to adhesions Heterophoria Alternating Cyclophoria Esophoria Exophoria Vertical Heterotropia Intermittent Hypertropia/hypotropia Latent Mechanical Brown s sheath syndrome Other (specify) Monofixation syndrome Educational Services/HIM 02/17/14 Page 3 of 8

4 Disorders of Ocular Muscles, Binocular Movement, Accommo-dation,and Refraction Continued Disorders of Refraction& Accommoda-tion Retinopathy of Prematurity Nasolacrimal Stenosis Ptosis of Eyelid Paralytic Third nerve palsy Fourth nerve palsy Sixth nerve palsy Total (external) ophthalmoplegia Progressive external ophthalmoplegia Kearns-Sayre Syndrome Other paralytic strabismus (specify) Vertical (hypertropia) Hypermetropia Myopia Astigmatism Regular Irregular Anisometropia Aniseikonia Presbyopia Disorders of accommodation Internal ophthalmoplegia Paresis of accommodation Spasm of accommodation Other disorders of refraction (specify) Retrolental fibroplasia Retinopathy of Prematurity Stage 0-5 (specify stage) Laterality Specify Site Nasolacrimal duct Lacrimal canaliculi Lacrimal punctum Lacrimal sac Congenital Mechanical Myogenic Neurogenic Paralytic Educational Services/HIM 02/17/14 Page 4 of 8

5 Congenital Eye/Eyelid Anomalies Eyelid, lacrimal apparatus and orbit Ptosis Ectropion Entropion Other anomaly of eyelid (specify) Absence/Agenesis of lacrimal apparatus Stenosis/Stricture of lacrimal duct Other anomaly of lacrimal duct (specify) Malformation of orbit Eye Cystic eyeball Anophthalmos Microphthalmos Macrophthalmos Lens Congenital cataract Congenital displaced lens Coloboma of lens Congenital aphakia Spherophakia Other lens anomalies (specify) Anterior segment Coloboma of iris Absence of iris Congenital corneal opacity Blue sclera Other (specify) Posterior segment Anomaly of vitreous humor Anomaly of retina Anomaly of optic disc Anomaly of choroid Other (specify) Congenital glaucoma Other (specify) Educational Services/HIM 02/17/14 Page 5 of 8

6 Conjunctivitis Allergic Atopic Chemical identify chemical Due to or In (for example) Acanthamoeba Adenovirus Chlamydia Coxsackie virus Diphtheria Enterovirus Filariasis Gonococci Granular Herpes Simplex Zoster Infectious disease (specify) Meningococci Mucocutaneous leishmaniasis Rosacea Syphillis Epidemic Follicular Giant papillary Hemorrhagic Infantile Mucopurulent Neonatal Parasitic (specify) Pseudomembranous Serous except viral Simple Trachomatous Acute Granular Sequelae (specify late effect) Traumatic Educational Services/HIM 02/17/14 Page 6 of 8

7 Conjunctivitis Continued Injuries of Eye and Orbit Toxic Vernal Viral Adenovirus Enterovirus Other (specify) Episode of Care Initial Subsequent Sequela Specify detailed location (eyelid, periocular, conjunctiva, cornea, eyeball, lacrimal apparatus) Type of Injury Abrasion/superficial injury Blister Contusion Foreign body Insect bite Laceration With prolapse or loss of intraocular tissue Penetrating Puncture wound Other Cause of Injury Mechanism How it happened (struck by basketball) Place of Occurrence Where it happened (high school) Activity What was happening (playing basketball) External Cause Status Military, Civilian, Work-related, Leisure (leisure) Educational Services/HIM 02/17/14 Page 7 of 8

8 Follow-Up Visits Please Note: Injuries continue to be coded to the initial injury with a subsequent encounter code extension Aftercare (requiring continued care) Medical Change or removal of dressing Other (specify) Surgical Change or removal of surgical dressing Removal of sutures Other (specify) Follow Up Exam after completed medical or surgical treatment (medical surveillance no further treatment needed) Educational Services/HIM 02/17/14 Page 8 of 8