ICD-10 essentials for busy physicians who would rather be doing something else: Ophthalmology


When a patient has a serious visual impairment, physicians of any specialty who participate in the care of that patient need to know about it. Hopefully that means you are all good citizens and get the information into the health record and eventually into the coded data, so that such impairments reflect the real cost of care and the tracking of outcomes. Or not. You all know what’s involved.

ICD-10 has added quite a bit of detail for describing some of the diseases and disorders of the eye. Others are essentially untouched beyond the ability to specify which eye is affected. Blog space being by definition a virtual cubbyhole, I will just touch on a few of these: glaucoma, cataracts and general codes for characterizing level of vision.

Glaucoma
Let me just say it up front -- this is a lot of new detail. And as rightly observed by my nephew Josh the ophthalmologist, this kind of detail isn’t known at the outset. Not a problem. As always with ICD-10 there is an unspecified glaucoma code whenever you need it, for as long as you need it.

H40.9 Unspecified glaucoma

So to spin this for all its worth -- when you are ready for some extreme glaucoma diagnosing fun, ICD-10 is ready for you! Some types allow you to capture whether the specific type of glaucoma is present in the left eye, the right eye or both eyes. Other types (presumably those that always affect both eyes) allow you to specify the stage of the glaucoma as mild, moderate, severe, indeterminate or unspecified within the glaucoma code. In ICD-9, stage must be coded separately. For those types where stage can be coded, I have added stage in parentheses to the glaucoma types below.

  • Primary angle closure without glaucoma damage 
  • Low-tension glaucoma (stage) 
  • Pigmentary glaucoma (stage) 
  • Capsular glaucoma with pseudoexfoliation of lens 
  • Residual stage of open-angle glaucoma (stage) 
  • Acute angle-closure glaucoma 
  • Chronic angle-closure glaucoma (stage) 
  • Intermittent angle-closure glaucoma 
  • Residual stage of angle-closure glaucoma 
  • Glaucoma secondary to eye trauma (stage) 
  • Glaucoma secondary to eye inflammation (stage) 
  • Glaucoma secondary to other eye disorders (stage) 
  • Glaucoma secondary to drugs (stage) 
  • Glaucoma with increased episcleral venous pressure 
  • Hypersecretion glaucoma 
  • Absolute glaucoma

Cataracts
Other than the fact that cataract coding has gone politically correct, there is very little to report that should require you to change your coding and documentation habits. The word senile in ICD-9 has been replaced with age-related in ICD-10, and nonsenile replaced with infantile and juvenile (never mind that infantile and juvenile have pejorative connotations of their own). I trust you can navigate those with no difficulty.

Age-related cataracts are classified into the exact same sub-types in ICD-10, for example, cortical and posterior subcapsular polar. They have simply been expanded to allow you to specify which eye is affected. Since, according to the data, not many of you use the specific codes in ICD-9, ignoring them in ICD-10 should be just as easy.

By a healthy margin, the most used code in ICD-9 is the unspecified senile cataract code. In ICD-10 the code is equally vague. In fact, unlike the other cataract codes, it doesn’t even allow you to specify which eye has the cataract. (Perhaps this is meant to motivate you to use one of the more specific codes.) Anyway, here it is.

H25.9 Unspecified age-related cataract

Replaces

366.10 Senile cataract, unspecified

Level of vision codes
Codes characterizing level of vision show up in the data a lot, so bravo for documenting level of visual impairment. The change in number of codes is trivial -- 17 in ICD-10, 16 in ICD-9 -- but the changes to the codes themselves are significant. The slippery ICD-9 terminology used to characterize visual impairment has been jettisoned and replaced in ICD-10 with two clear, simple distinctions. In ICD-10 you are either blind or you have low vision.

H54.41 Blindness, right eye, normal vision left eye 
H54.42 Blindness, left eye, normal vision right eye 

Replaces

369.63 One eye: total vision impairment; other eye: normal vision 
369.66 One eye: near-total vision impairment; other eye: normal vision 
369.69 One eye: profound vision impairment; other eye: normal vision 

H54.50 Low vision, one eye, unspecified eye 
H54.51 Low vision, right eye, normal vision left eye 
H54.52 Low vision, left eye, normal vision right eye

Replaces

369.70 Moderate or severe impairment, one eye, impairment level not further specified

(An internist friend who asked that his name be withheld confesses that he hasn’t a clue what the definition of low vision is. For those of you who are similarly “challenged,” here is a definition, courtesy of low-vision.org:  Low vision is a significant reduction of visual function that cannot be fully corrected by ordinary glasses, contact lenses, medical treatment and/or surgery. )

ICD-10 codes also are available to describe blindness in one eye and low vision in the other, for example, H54.11 Blindness, right eye, low vision left eye. And they have not messed with a good thing -- they kept the code for legal blindness, shown below.

H54.8 Legal blindness, as defined in U.S.A.

Replaces

369.4 Legal blindness, as defined in U.S.A.

Hopefully you will welcome these few modest improvements and can efficiently ignore the detail that you cannot or do not choose to use. That is what an upgrade allows you to do, after all.

Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC.  She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.

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