ICD-10-CM Training – Chapter 7 © 2013 Amphion Medical Solutions Amphion ICD-10-CM Training Faculty: Alisa Engel, RHIT, CPC-H AHIMA Approved ICD-10 Trainer Amphion Education Consultant Julie Harbert, RHIA AHIMA Approved ICD-10 Trainer Amphion Education Consultant

Diseases of the Eye and Adnexa 2

2013 Copyright Amphion Medical Solutions p. 599 ICD-10-CM Chapter 7. Diseases of the eye and adnexa (H00-H59) INSTRUCTIONAL NOTE: Use an external cause code following the code for the eye condition, if applicable, to identify the cause of the eye condition Chapter 7 3

New concepts in ICD-10-CM: We now specify laterality in many codes using: Right Left Bilateral (if no code available, assign two codes – one for right and one for left Unspecified The term “age-related” has replaced “senile” when referring to cataracts 4 Chapter 7

2013 Copyright Amphion Medical Solutions p. 580 ICD-10-CM p. 583 ICD-10-CM H47.5Disorders of other visual pathways Code also underlying condition H54 Blindness and low vision Code first any associated underlying cause of the blindness Chapter 7 5

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.38 a. Glaucoma 1) Assign glaucoma code Assign as many codes from category H40 Glaucoma, as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage. 2) Bilateral glaucoma with same type and stage When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage. p. 575 ICD-10-CM Chapter 7 6

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.38 a. Glaucoma, continued 2) Bilateral glaucoma with same type and stage When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and the classification does not provide a code for bilateral glaucoma (i.e. subcategories H40.10, H40.11 and H40.20) report only one code for the type of glaucoma with the appropriate seventh character for the stage. Chapter 7 7

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.39 a. Glaucoma, continued 3) Bilateral glaucoma with different types or stages When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. p. 575 Example: Patient has bilateral low-tension glaucoma, mild in left eye and moderate in right eye H Low-tension glaucoma, left eye, mild H Low-tension glaucoma, right eye, moderate Chapter 7 8

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.39 a. Glaucoma, continued 3) Bilateral glaucoma with different types or stages When a patient has bilateral glaucoma and each eye is documented as having a different type, and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), assign one code for each type of glaucoma with the appropriate seventh character for the stage. p. 575 Example: Patient has bilateral glaucoma, mild open-angle in right eye, moderate primary open-angle in left eye H40.11x2 Primary open-angle glaucoma, moderate (left eye) H40.10x1 Unspecified open-angle glaucoma, mild (right eye) Chapter 7 9

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.39 a. Glaucoma, continued 3) Bilateral glaucoma with different types or stages When a patient has bilateral glaucoma and each eye is documented as having the same type, but different stage, and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), assign a code for the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye. p. 621 Example: Patient has bilateral primary open-angle glaucoma, mild in the right eye, moderate in the left eye H40.11x2 Primary open-angle glaucoma, moderate (left eye) H40.11x1 Primary open-angle glaucoma, mild (right eye) Chapter 7 10

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.39 a. Glaucoma, continued 4) Patient admitted with glaucoma and stage evolves during the admission If a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented. Chapter 7 11

2013 Copyright Amphion Medical Solutions Official Coding Guidelines p.39 a. Glaucoma, continued 5) Indeterminate stage glaucoma Assignment of the seventh character “4” for “indeterminate stage” should be based on the clinical documentation. The seventh character “4” is used for glaucomas whose stage cannot be clinically determined. This seventh character should not be confused with the seventh character “0”, unspecified, which should be assigned when there is no documentation regarding the stage of the glaucoma. Chapter 7 12

2013 Copyright Amphion Medical Solutions p. 109 Coder Training Manual Case 1.53 H Cortical age-related cataract, right eye Cataract (cortical) (immature) (incipient), age-related, see Cataract, senile, cortical H Postprocedural hemorrhage and hematoma of right eye and adnexa following an ophthalmic procedure Hemorrhage, postoperative, see Complications, postprocedural, hemorrhage, by site Complication(s) (from) (of), postprocedural, hemorrhage (hematoma) (of), eye and adnexa, following ophthalmic procedure Chapter 7 13

2013 Copyright Amphion Medical Solutions Case 1.53 Y Ambulatory surgery center as the place of occurrence of the external cause External Cause of Injuries Index, Place of occurrence, same day surgery center Chapter 7 14

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