1. ANATOMY AND CODING OF THE EYE
Diana R Phelps, CPC, CPC-I, CEMC
Approved AAPC ICD-10-CM Instructor

2. OBJECTIVES Eye Care Specialist Understand the components of the eye
Common diagnoses
Evaluation and Management vs. Eye Codes
Modifiers
Surgical Procedures and Diagnosis

3. EYE CARE SPECIALISTS Ophthalmologist Optometrist Optician Ocularist
Medical doctor (MD)
Osteopathic physician (DO)
Optometrist
Doctor of optometry (OD)
Optician
Technician
Ocularist
Technician for prosthetics

4. ANATOMY OF THE EYE Accessory structures of the eye Eyelids Eyelashes
Covers the eyeball
Eyelashes
Protection from foreign bodies
Lacrimal apparatus
Located under the upper eyelid and below the eyebrow bilaterally, in the outer most corner of the eye
Tears form in the gland
Fluid secreted serves to clean the eye and moisturize the cornea and conjunctiva

5. ANATOMY OF THE EYE

6. ANATOMY OF THE EYE Sclera Choroid Conjunctiva Cornea
White part of the eyeball
Tough, most important job of covering most of the eyeball (outer coat)
Choroid
Carries blood vessels (pink threads), it is the inner coat between the sclera and the retina
Conjunctiva
Clear membrane covering the white of the eye (sclera)
Cornea
Part of the sclera in front of the colored part of the eye
It is transparent, or completely clear
Lets light travel through it
Helps eye focus as light makes its way through
Like clear glass, it gives your eye a clear window to view the world

7. ANATOMY OF THE EYE Iris Pupil Anterior Chamber
Behind the cornea and the pupil
Colorful part of the eye
It is a muscle that controls the amount of light entering the eye cavities (functions like the aperture on a camera)
Pupil
Black circle in the center of the iris
Lets light enter the eye
Big when it has little light
Small with more light
Anterior Chamber
Between the iris and cornea.
Filled with a special transparent fluid that gives the eye oxygen, protein, and glucose (aqueous humor)

8. ANATOMY OF THE EYE Lens Macula Retina Sits behind the iris
Clear and colorless
Job is to focus light rays on the back of the eyeball
Macula
Small area in the retina that provides our most central, acute vision
Retina
Very back of the eye, past the vitreous body
Holds millions of cells that are sensitive to light
Takes the light received and changes it into nerve signals so the brain can understand what the eye is seeing

9. ANATOMY OF THE EYE Ciliary Body Posterior chamber
Lens is suspended in the eye by a bunch of fibers and these fibers (muscles) attach to the lens
Produces aqueous humor
It’s job is to change the shape of the lens.
Posterior chamber
Biggest part of the eye and sits behind the lens
Forms two-thirds of the eye’s volume and gives the eye its shape
Filled with clear, jelly-like material called vitreous humor

10. ANATOMY OF THE EYE Optic Nerve Extraocular Muscles Fovea
Conducts visual impulses to the brain (a great messenger in the back of your eye that sends messages)
Serves as the high-speed telephone line connection
Extraocular Muscles
Muscles that move the eye up or down (vertical or horizontal)
Fovea
Defines the center of the retinal, and is the region of highest visual acuity

11. EXTRAOCULAR MUSCLES Extraocular muscles Moves the eyeball 6 muscles
Lateral rectus
Medial rectus
Inferior oblique
Inferior rectus
Superior oblique
Superior rectus

12. COMMON EYE DIAGNOSES Infections and inflammation Neoplastic disease
Injury
Glaucoma
Cataracts
Diabetic Retinopathy
Retinal detachment
Graves disease
Strabismus -

13. NEW PATIENT DEFINITION
A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from the physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
See Decision Tree in 2016 CPT Professional

14. EVALUATION AND MANAGEMENT
Chief complaint (evidence of medical necessity)
History
History of present illness (HPI) (location, duration, timing, severity, quality, content, modifying factors, sign and symptoms)
Review of systems (ROS)
Past history (PFSH)
Family history
Social history

15. 1995 EXAMINATION ELEMENTS Vital signs Iris Respiratory Pupil
Cardiovascular
Skin inspection
Visual Acuity (VA)
Confrontation (visual) fields
Ocular Motility
Conjunctiva
External Adnexa
Cornea
Tears
Iris
Pupil
Anterior Chamber
Lens
IOP
Fundus
Disc, C/D, Size
Reina, Vessels
Mental Status (Alert)
Mood, Affect

16. 1995 EXAMINATION ELEMENTS Problem focused Expanded problem focused
Detail
Comprehensive
Body area or system related to problem
2-7 elements
2-7 systems with detail
8 or more systems

17. 1997 EXAMINATION ELEMENTS Visual acuity Gross visual field
Ocular motility
Inspection conjunctivae
Ocular adnexae including lids, lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes
Examination of pupils and irises including shape, direct and consensual reaction, size
Slit lamp examination of the corneas including epithelium, stroma, endothelium and tear film
Slit lamp examination of the anterior chambers including depth, cells and flare
Slit lamp examination of lenses including clarity, anterior and posterior capsule, cortex and nucleus
Measurement of intraocular pressures (except children and patients with trauma or infectious disease)
Neurology-Orientation to time, place & person
Psychiatric –Mood and affect
Ophthalmoscopic examination through dilated pupils (unless contraindicated) of
Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor evaluation) and nerve fiber layer
Posterior segments including retina and vessels (eg, exudates and hemorrhages)

18. 1997 EXAMINATION ELEMENTS Problem focused Expanded problem focuses
Detail
Comprehensive
1-5 elements identified by a bullet
At least 6 elements identified by a bullet
At least 9 elements identified by a bullet
Perform all elements identified by a bullet plus Neurologic & Psychiatric

19. DECISION MAKING Diagnosis Tests Risk
Number of diagnoses or management options
Tests
Amount of data reviewed including tests, discussions with others, review of medical records, etc.
Risk
Severity of disease, triage (using the Table of Risk)

20. CODING GUIDELINES Chief complaint-Reason for visit Documentation
Still necessary
Documentation
To establish medical necessity
General medical observations
Require dilation for 92004/92014 (check carriers)
Must include initiation/continuation of diagnostic and treatment programs

21. EYE CODES (92002-92014) New Patient 92002
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient
92004
comprehensive, new patient, 1 or more visits
(Do not report or in conjunction with 99173, 99174, 99177)

22. EYE CODES (92002-92014) Established Patient 92012
Ophthalmologist services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
92014
comprehensive, established patient, 1 or more visits
(Do not report or in conjunction with 99173, 99174, 99177)

23. COMPREHENSIVE OPHTHALMOLOGICAL SERVICES
92004 & 92014
Introduction of CPT
General evaluation of the complete visual system (1or more sessions)
Includes:
History
General medical observation
External examination
Ophthalmoscopic examination
Gross visual fields
Basic sensorimotor examination
Often includes:
Biomicroscopy
Examination with cycloplegia or mydriasis
Tonometry
Always includes:
Initiation/continuation of diagnostic and treatment programs

24. DIAGNOSTIC AND TREATMENT PROGRAM
Includes, but not complete list:
Prescription of medication
Special ophthalmological diagnostic or treatment:
Services
Consultations
Laboratory procedures
Radiological services

25. INTERMEDIATE OPHTHALMOGICAL SERVICES
92002 & 92012
Introduction of CPT
Evaluation of new/existing condition by new diagnostic/management problem not necessarily related to primary diagnosis
Includes:
History
General medical observation
External examination
Adnexal examination
May Include:
Other diagnostic procedures
Mydriasis of ophthalmoscopy
Always includes:
Initiation/continuation of diagnostic and treatment programs

26. ELEMENTS OF EXAMINATION
Confrontation fields
Eyelids/adnexa
Ocular motility
Pupils/Iris
Cornea
Lens
Intraocular pressure
Retina (vitreous, macula, periphery, and vessels)
Optic disc
(Should be 12 elements including acuity and bulbar and palpebral conjunctiva but not always listed)

27. INTERMEDIATE vs. COMPREHESIVE
Comprehensive
History
General medical observation
External ocular and adnexal exam
Other diagnostic procedures as indicated
May include mydriasis
History
General medical observation
External and ophthalmoscopic exam
Gross visual fields
Basic sensorimotor exam
Often includes Biomicroscopy, exam with cycloplegia or mydriasis and tonometry
Always includes initiation of diagnostic and treatment programs

28. E/M vs. EYE CODES Complicated Multiple documentation guidelines
5 Levels
Reimbursement varies
Simple definitions
Easy documentation
2 Levels
Initiation diagnostic & treatment program(s)
Higher Reimbursement
Dilation required by some carriers

29. SPECIAL TESTS INCLUDED
The following special tests have no individual CPT code and they can be included in general ophthalmologic exams
Laser interferometry
Potential acuity meter
Keratometry
Exophthalmometry
Transillumination
Corneal sensation
Tear film adequacy
Phacometry
Schirmer’s test
Slit lamp
History
General medical observation

30. SURGERY MODIFIERS Modifiers for surgery
22-Increased procedural services
50-Bilateral procedure
51 Multiple procedures
52-Reduced services
53-Discontinued services
54-Surgical care only
55-Postoperative management only
56-Preoperative management only
58-Staged or related procedure (during PO)
59-Distinct procedural service

31. SURGERY MODIFIERS 62-Two surgeons
76-Repeat procedure by same physician
77-Repeat procedure by another physician
78-Unplanned return to OR/Procedure room by the same physician following initial procedure for a related procedure..
79-Unrelated procedure or service by the same physician during the PO period
LT-left
RT-right
E1-E4 Eyelid modifiers

32. REMOVAL OF EYE Evisceration- contents of eye removed, but sclera left
65091 – Evisceration of ocular contents; without implant
65093 – with implant
Enucleation- entire eye removed
65101 – Enucleation of eye; without implant
65103 – with implant, muscles not attached to implant
65105 – with implant, muscles attached to implant
(For conjuctivoplasty after enucleation, see et seq)
Exenteration- contents of the eye socket removed
65110 – Exenteration of orbit (does not include skin graft)
65112 – with therapeutic removal of bone
65114 – with muscle or myocutaneous flap
(For skin graft to orbit (split skin), see 15120, 15121; free, full thickness, see 15260, 15261)
(For eyelid repair involving more than skin, see et seq)

33. GLAUCOMA SURGERY ICD-10-CM code(s) H40.- or Q15.0
Glaucoma – is a group of diseases that damage the eye’s optic nerve and can result in vision loss and blindness. However, with early detection and treatment, you can often protect your eyes against serious vision loss.
66625 – Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure)
66630 – sector for glaucoma (separate procedure)
66700 – Ciliary body destruction; diathermy
66710 – cyclophotocoagulation, transscleral
66711 – cyclophotocoagulation, endoscopic
66720 – cryotherapy
66761 – Iridotomy/Iridectomy by laser surgery (eg, for glaucoma) (per session)
ICD-10-CM code(s) H40.- or Q15.0

34. CATARACT SURGERY
Cataract – a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision.
66982 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg. irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg. iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage
(For insertion of ocular telescope prosthesis including removal of crystalline lens, use 0308T)
66983 – Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)
(Do not report in conjunction with 0308T)
66984 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)
(For complex extracapsular cataract removal, use 66982)
ICD-10-CM Code(s) H26.-H28. , Q12.0, E10.3- , E11.3-, etc.

35. STRABISMUS SURGERY ICD-10-CM code(s) H50.-
Strabismus – correcting the eye direction
67311 – Strabismus surgery, recession or resection procedure; 1 horizontal muscle
67312 – 2 horizontal muscles
67314 – 1 vertical muscle (excluding superior oblique)
67316 – 2 or more vertical muscles (excluding superior oblique)
Several other codes are listed
This is horizontal ---
ICD-10-CM code(s) H50.-

36. CHALAZION REMOVAL Chalazion ICD-10-CM Code(s) H00.1-
Lump that forms due to blockage/swelling of an oil gland
67800 – Excision of Chalazion; single
67801 – multiple, same lid
67802 – multiple, different lids
67808 – under general anesthesia and/or requiring hospitalization, single or multiple
ICD-10-CM Code(s) H00.1-

37. TRICHIASIS SURGERY Trichiasis ICD-10-CM Code(s) H02.05-
Eyelashes are ingrown or misdirected
67820 – Correction of trichiasis; epilation, by forceps only
67825 – epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery)
67830 – incision of lid margin
67835 – incision of lid margin, with free mucous membrane graft
ICD-10-CM Code(s) H02.05-

38. LAGOPHTHALMOS SURGERY
Not able to close eyes
67912 – Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight)
ICD-10-CM Code(s) H02.2-

39. ECTROPION SURGERY Ectropion ICD-10-CM Code(s) H02.1-
Eyelid turns outward
67914 – Repair of ectropion; suture
67915 – thermocauterization
67916 – excision tarsal wedge
67917 – extensive (eg. Tarsal strip operations)
(for correction of everted punctum, use 68705)
ICD-10-CM Code(s) H02.1-

40. ENTROPION SURGERY Entropion ICD-10-CM Code(s) H02.0-
Eyelid turns inward
67921 – Repair of entropion; suture
67922 – thermocauterization
67923 – excision tarsal wedge
67924 – extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation)
(For repair of cicatricial ectropion or entropion requiring scar excision or skin graft, see also et seq.)
ICD-10-CM Code(s) H02.0-

41. MACULAR DEGENERATION ICD-10-CM code(s) H35.-
Macular Degeneration is the leading cause of vision loss, affecting more than 10 million Americans - more than cataracts and glaucoma combined.
Treating the wet form of macular degeneration may involve the use of anti- VEGF treatment, thermal laser treatment or photodynamic therapy (PDT). Treatment of wet macular degeneration generally reduces—but does not eliminate-- the risk of severe vision loss.
No treatment for the dry.
ICD-10-CM code(s) H35.-

42. QUESTIONS