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ICD-10-CMTraining – Chapter 7
© 2013 Amphion Medical Solutions
Amphion ICD-10-CM Training Faculty:
Alisa Engel, RHIT, CPC-HAHIMA Approved ICD-10 TrainerAmphion Education [email protected]
Julie Harbert, RHIAAHIMA Approved ICD-10 TrainerAmphion Education [email protected]
2013 Copyright Amphion Medical Solutions
p. 599 ICD-10-CMChapter 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
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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
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p. 580 ICD-10-CMp. 583 ICD-10-CMH47.5 Disorders of other visual pathways
• Code also underlying condition
H54 Blindness and low vision• Code first any associated underlying cause of the blindness
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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
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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.
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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. 575Example: Patient has bilateral low-tension glaucoma, mild in left eye and
moderate in right eyeH40.1221 Low-tension glaucoma, left eye, mild
H40.1212 Low-tension glaucoma, right eye, moderate
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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. 575Example: Patient has bilateral glaucoma, mild open-angle in right eye,
moderate primary open-angle in left eyeH40.11x2 Primary open-angle glaucoma , moderate (left eye)
H40.10x1 Unspecified open-angle glaucoma, mild (right eye)
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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. 621Example: Patient has bilateral primary open-angle glaucoma, mild in the
right eye, moderate in the left eyeH40.11x2 Primary open-angle glaucoma , moderate (left eye)
H40.11x1 Primary open-angle glaucoma, mild (right eye)
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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.
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Official Coding Guidelines p.39• a. Glaucoma, continued
5) Indeterminate stage glaucomaAssignment 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.
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p. 109 Coder Training ManualCase 1.53H25.011 Cortical age-related cataract, right eye
Cataract (cortical) (immature) (incipient), age-related, see Cataract, senile, cortical
H59.311 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
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Case 1.53Y92.530 Ambulatory surgery center as the place of occurrence of the
external causeExternal Cause of Injuries Index, Place of
occurrence, same day surgery center
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