Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., Rebecca Wartman, O.D.
From the November/December 2016 edition of AOA Focus, page 48-49.
On Oct. 1, 2016, hundreds of new ICD-10 codes that impact doctors of optometry went into effect.
Several additions and revisions have been made in Chapter 4 of the ICD-10 code set (endocrine, nutritional and metabolic diseases). This chapter includes diabetes-related diagnosis codes.
Because doctors of optometry perform the majority of comprehensive, dilated eye examinations for people with diabetes in the United States and are well versed in the treatment and management of diabetic eye disease, it is critical that doctors of optometry are aware of these updated codes.
In addition to the diabetes code changes, many other code changes have occurred. Included in this column are just a few of these important changes.
New 'code additional' requirements for type II diabetes (E11)
The ICD-10 guidelines provide direction on the sequence for reporting certain conditions. The guidelines indicate, "Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a 'use additional code' note at the etiology code and a 'code first' note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation."
For type II diabetes (E11), the "use additional" instructions have changed. Previously physicians were guided to use an additional code to identify any insulin use (Z798.4). As of Oct. 1, 2016, physicians have been instructed to report use additional code to identify control using insulin (Z79.4); oral antidiabetic drugs (Z79.84); or oral hypoglycemic drugs (Z79.84.)
Additional specificity to define laterality
Certain subcategories of diabetes codes will now require that a seventh character be assigned to each code to designate laterality.
The impacted subcategories are:
- E11.32 type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy
- E11.33 type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy
- E11.34 type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy
- E11.35 type 2 diabetes mellitus with proliferative diabetic retinopathy E11.37 type 2 diabetes mellitus with diabetic macular edema, resolved following treatment
The seventh character to be added to each of the following subcategories are:
- 1 right eye
- 2 left eye
- 3 bilateral
- 9 unspecified
Please refer to your Codes for Optometry manual for the full listing of codes.
New codes for type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment
The four new codes are:
- E11.352 type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula
- E11.353 type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula
- E11.354 type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment
- E11.355 type 2 diabetes mellitus with stable proliferative diabetic retinopathy
For a complete listing of the new codes, doctors should purchase the Codes for Optometry manual available at AOA Marketplace.
Ask the coding experts
If you have any questions regarding Medical Records and Coding, please submit them by using the Coding Experts Submission Form and one of our coding experts will be in contact with you.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.