ICD-9 CM. ICD-9 9 CM stands for International Classification of Diseases, 9 th revision, clinical modifications

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1 Ophthalmology Coding ICD-9 9 CM & CPT By Alice Landry, Registered Health Information Administrator and Certified Procedural Coder Harvey & Bernice Jones Eye Institute University of Arkansas for Medical Sciences

2 ICD-9 CM ICD-9 9 CM stands for International Classification of Diseases, 9 th revision, clinical modifications ICD-9 9 CM is used for coding diagnoses and procedures done in the hospital. Example: glaucoma, open angle (diagnosis code); trabeculectomy (hospital procedure code). This information is then used for billing, research and statistics. ICD-9-CM CM Volumes 1 & 2 refer to illnesses and injuries. Volume 3 refers to hospital procedures.

3 Most of the diagnoses used in Ophthalmology come from the Nervous System and Sense Organs ( ) 379) section of ICD-9. Most ICD-9 9 codes consist of four or five digits. These digits provide specificity. Example: 362 can be expanded to Diabetic Retinopathy. The symbol next to this code alerts you to use a fifth digit: Background diabetic retinopathy; Proliferative diabetic retinopathy. Example: 365 can be expanded to , Open angle glaucoma, unspecified and , Primary open angle glaucoma.

4 V-codes V-codes are supplementary ICD-9 9 codes that are used when a person who is not currently sick comes in for a specific purpose, such as a vaccination. They re also used when a patient with a known disease or injury comes in for aftercare following surgery, is on high- risk medication (such as Plaquenil, V58.69), etc. If a patient has a condition that may affect his/her health status (such as being HIV positive but not having AIDS), then a V code would be used to describe this. If a patient is pseudophakic (V43.1) or has an ocular prosthesis (V43.0), these V codes help to identify why the patient is being seen.

5 Sometimes ICD-9-CM CM requires you to use two codes for one diagnosis: e.g. background diabetic retinopathy (type II diabetes) or (type I diabetes) must be assigned along with Therefore, the code for background diabetic retinopathy (type II diabetes) would be , When billing, each code would have to be entered.

6 E-Codes E-codes describe causes of injury, poisoning, and other adverse effects. E-codes E are never used as a primary (first listed) diagnosis codes.

7 CPT CPT or Current Procedural Terminology is developed by the American Medical Association for reporting medical services. CPT codes are used to identify procedures performed in the outpatient tient and physician settings. Most CPT codes used in Ophthalmology come from f the Eye and Ocular Adnexa section (e.g.yag capsulotomy ). Ophthalmological services such as visual field testing come from the Medicine section (e.g. fluorescein angiography 92235) or the Radiology section (pachymetry 76514). CPT is also used to bill for office visits and are coded either by using E/M (evaluation and management) service codes ( ) or eye examination codes ( ). These E/M and eye examination codes are usually listed on an encounter form, which is used for billing purposes. The physician and/or tech then checks off the appropriate code that they feel best reflects the amount of time and effort utilized when seeing the patient.

8 New and Established Patients Physician Charges Office visits are described as either new patient or established patient. The physician will choose to mark either an evaluation and management (E/M) service code or an eye examination code on an encounter form. Eye examination codes are used only in Ophthalmology and are found in the Medicine section of CPT, whereas eas E/M services has its own section in the CPT book. A new patient is described as one who has not been seen in the clinic c within the last three years. Therefore, if the patient has been seen within this time period, he/she is classified as being an established patient. New patient E/M codes fall within the range. New patient eye examination codes are either (new, intermediate) or (new, comprehensive). Established patient E/M codes fall within the range. Established patient eye examination codes are either (established, intermediate) or (established, comprehensive). The physician will determine which of the above codes to use.

9 Modifiers Modifiers are used to provide additional information about services provided to patients. Medicare and private payers need these for further specificity. 50 Modifier used to identify a procedure performed bilaterally. Example: A fluorescein angiogram was done on a patient: CPT code would be used. If this was done to check for a condition involving both eyes, a modifier 50 would be used to identify this. Therefore the code would look like this: RT and LT modifiers: Some payers require the use of RT (right) and LT (left) modifiers instead of -50. If this is the case, then the codes would look like this: RT, LT and would be submitted on two lines on the billing form. Appendix A in the back of the CPT book lists all modifiers and gives g a description of each.

10 Modifiers Modifiers are very important because they can affect payment. For instance, -25 modifiers are used to show private payers that a procedure performed was separate from the usual office visit and shouldn t t be included in the office visit charge. Example: A patient comes in with trichiasis. Eyelashes are epilated. An office visit would be charged using either an E/M or an eye examination code and a modifier -25 attached to it to show the payer that it was separate from the visit. Then, the code for the procedure (epilation) would be coded. Example: (new patient eye exam), (epilation with forceps). TC modifiers identify the technical component of a procedure. Example: A-A scan IOL has a professional component and a technical component. If a facility provides just the technical component (i.e. the administration of an A scan and the test is sent to another physician s s office for him/her to read, then one would attach a modifer -TC to the code. The physician s s office would attach a -26 modifier (professional component) to the code when they charge for it.

11 Consult Visits Physicians can charge a new patient a consult visit if the patient has been referred from a physician in another specialty. Example: A comprehensive ophthalmologist can refer a patient to a cornea specialist or a retina specialist. The E/M codes for these visits are in the range of are used for outpatient visits are used for inpatient visits.

12 Documentation Documentation is very important. One should always remember that if it isn t t noted, the person reading the chart may assume it didn t happen. The way documentation is worded can also affect whether a claim will be paid or not. For instance, care should be taken when noting the chief complaint or the reason a patient is being seen. Don t t write: Patient presents today for annual exam if the patient is returning for a diabetic eye evaluation or a glaucoma check. Don t t write: No problems, no complaints if vision is 20/80 OU due to cataracts. Not only would this not reflect the true reason the patient is being b seen, it could mean a denial of a claim. Documentation should also reflect the reason a procedure is being performed. Coders rely on this documentation so that they can correctly identify which codes are to be used. Not only can this affect reimbursement, it can also adversely affect patient care.

13 References CPT Current Procedural Terminology, Professional Edition, American Medical Association, Chicago, IL, ICD-9-CM CM 2006 Expert for Hospitals, Volumes 1, 2 and 3. International Classification of Diseases, 9 th Revision, Clinical Modification, Sixth Edition, U.S. Department of Health and Human Services, Ingenix, Inc., Salt Lake City, UT, 2005.