Coding Tips – Bilateral glaucoma with different types or stages

In this blog post, we will discuss about the coding guidelines for bilateral glaucoma conditions with different types or stages. For bilateral glaucoma conditions, you always need to check whether both the eyes are affected with same type of glaucoma or different type and the appropriate stages to assign the correct codes.

Coding becomes more challenging when the patient has glaucoma in both the eyes. When a patient has a different type and/or a different stage, you need to assign a separate code for each eye with the proper type, laterality, and appropriate 7th character for the stage. Let us discuss with few examples for better understanding.

Scenario 1: 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 as shown in the fig.1 and the classification provides the laterality codes, then you need to assign separate codes for each eye with the proper type, laterality and appropriate seventh character for the stage.

In this example, right eye is affected with primary open angle glaucoma with moderate stage and left eye is affected with pigmentary glaucoma with mild stage. As per ICD-10 CM guidelines, you need to assign separate codes for each eye rather than the code for bilateral glaucoma.

Figure: 1

Scenario 2: Bilateral glaucoma with same type but different stages:

When a patient has bilateral glaucoma and each eye is documented as having the same type but different stages, then you need to assign the appropriate code for each eye to capture the particular stage of each eye documented.

In this example, both right and left eyes are affected with the same type (chronic angle closure), but different stages in each eye. The right eye is documented as moderate (seventh character 2) and the left eye is documented as mild stage (seventh character 1).As per ICD-10 CM guidelines, you need to assign the appropriate code for each eye rather than the code for bilateral glaucoma.

Figure 2:

Subcategories H40.10 and H40.20:

In this subcategory, the classification does not distinguish laterality in the code sets. Therefore if the patient has bilateral glaucoma and each eye is documented as having different type, then you need to assign one code for each type of glaucoma with the appropriate seventh character for the stage.

If the patient has bilateral glaucoma and each eye has the same type but different stage, then you need to assign a code for the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye.

References:

https://www.aao.org/Assets/5adb14a6-7e5d-42ea-af51-3db772c4b0c2/636713219263270000/bc-2568-update-icd-10-quick-reference-guides-glaucoma-final-v2-color-pdf?inline=1
https://www.healthicity.com/blog/icd-10-reminder-series-section-1c7-disease-eye-adnexa.

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