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Code This!

Scenario Week of October 27, 2011:
View Current Scenario

CHIEF COMPLAINT: Visual disturbances

A 52-year old male presents to the ophthalmology clinic as a new patient. He has experienced a recent onset of decreased visual acuity and visual disturbances. He has spent the past five years overseas, during which he has postponed regular eye exams. Onset of current symptoms began a few months ago with minor perceived visual disturbances and changes in his vision. Since that time, his visual changes have progressed to the point that he experiences “blind spots” in his peripheral visual field. He admits to a family history of glaucoma, with a maternal grandmother who lost her sight from the disease, although the age of the grandmother at the time of onset and type of glaucoma are unknown.

Comprehensive bilateral eye examination was performed with basic gross visual field assessment utilizing autorefractors and aberrometers, sensorimotor examinations, biomicroscopy, cycloplegia, and mydriasis. Upon identification of elevated IOP via applanation tonometry, additional testing was initiated. In addition to the basic exam, extended visual field testing, determination of refractive state, gonioscopy, and fundus photography were performed with interpretation and report. Results of extended testing revealed high IOP, despite free flow of aqueous and atrophic cupping of the optic disc. Serial tonometry was performed in three sequential readings to rule out acute angle closure.

DIAGNOSIS: Findings are consistent with moderate primary open angle glaucoma. The patient was prescribed topical combination pharmacotherapy and was scheduled to return for follow-up examination and IOP measurements.

Assign the appropriate ICD-9-CM diagnosis and procedure codes, and the appropriate CPT code.

ICD-9-CM Diagnosis Codes
365.11 Primary open angle glaucoma

365.72 Moderate stage glaucoma

V19.11 Family history of glaucoma

ICD-9-CM Rationale
Effective October 1, 2011, instructional notes have been added at subcategories 365.1–365.6 prompting for the assignment of an additional code to identify the specific stage of glaucoma, represented by new ICD-9-CM subcategory 365.7. This new subcategory includes a sequencing instruction to code first the glaucoma, by type. Report new code V19.11 Family history of glaucoma, where appropriate.

CPT Procedure Codes
92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, comprehensive, new patient, 1 or more visits

92083-59 Visual field examination, unilateral or bilateral with interpretation and report; extended examination

92015-59 Determination of refractive state

92100-59 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over and extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure)

92250-59-50 Fundus photography with interpretation and report

CPT Rationale
Code 92004 indicates that a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Gross or general visual field examination, (92071–92083) such as confrontation testing, provides a general estimate of peripheral vision and is included in general ophthalmologic examination and evaluation; however, when provided as special ophthalmological services, it may be separately reported. Otherwise, it is not reported separately. Similarly, gonioscopy (92020) is usually a component of a more complex service and is not identified separately. However, when performed alone or with other unrelated procedures/services, it may be reported. Code 92015 is a bilateral procedure that is not included in the general ophthalmological service and may be reported separately when performed. Bilateral procedures do not require modifier 50.

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