By Rebecca H. Wartman, OD
On October 1, 2016, changes to ICD-10-CM coding were implemented. While all of the code changes applicable for optometry are important, a few of the major changes are discussed in this article.
Diabetic Ocular Complication Codes
The first major change in ICD-10-CM codes for 2017 is for diabetic ocular complication coding. All of the DM retinopathy code choices will now specify which eye is impacted. Several new codes for proliferative diabetic retinopathy were also added. Note that a code for oral diabetic medication use (Z79.84) was added and should be used when applicable. The existing code to designate insulin use (Z79.4) was retained. Keep in mind that not all injectable diabetic medications are considered insulin. If a patient is on both oral medication and insulin, both of these medication codes should be used.
The new codes for diabetic retinopathy apply to all the code categories, but only the E11.3 code section is detailed in this article so be sure to review the other categories if you are using them for any particular patient. The other categories include E08.3, E09.3, and E10.3.
E11.3 Type 2 diabetes mellitus with ophthalmic complications
All of the subcategories under E11.3, with two exceptions, will require a 7th character to indicate which eye had retinopathy. One exception is E11.36 Type 2 diabetes mellitus with diabetic cataract. The other exception is E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication, but this code does require the use of an additional code to further describe the complication.
The ICD-10-CM tabular listing for each of the following subcategories will require the following 7th character to be added as indicated by this statement under each subcategory: E11.32, E11.33, E11.34, and E11.35.
As an example, all of the nonproliferative diabetic retinopathy codes are included for the use of this 7th character similar to the E11.32 code:
E11.32 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy
Type 2 diabetes mellitus with nonproliferative diabetic retinopathy NOS.
The 7th characters to be assigned to codes in subcategory E11.32 are:
1 - right eye
2 - left eye
3 - bilateral
9 - unspecified eye
E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
If each eye has a different level of retinopathy, the provider will need two codes. For example, in a patient with mild retinopathy without macular edema in the right eye and severe retinopathy without macular edema in the left eye, the following codes would be used: E11.3211 and E11.3412
There are several changes to the proliferative diabetic retinopathy codes for 2017. The subcategories are as follows and all are eye specific using the 7th character added to the codes.
E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
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
E11.37 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment
Primary Open Angle Glaucoma Codes
The commonly used primary open angle glaucoma codes have changed. These codes are now per eye. And the appropriate 7th character to specify which stage of glaucoma is still added to these codes. The 7th characters for stage have not changed. If the type of glaucoma and the stage is the same for both eyes, then only one code will be required. However, if the stage and/or type of glaucoma is different between each eye, two codes will be required. The new required eye designation has taken the place of the “x” in the 6th character spot to indicate which eye:
H40.111 Primary open-angle glaucoma, right eye
H40.112 Primary open-angle glaucoma, left eye
H40.113 Primary open-angle glaucoma, bilateral
Macular Degeneration Codes
Macular degeneration codes have also changed. These codes now indicate which eye is impacted along with the stage of the disease for each eye indicated by a new 7th character. These 7th characters are different from the 7th characters used with other codes, including exudative macular degeneration. If each eye is in a different stage, two codes would be required.
The 7th characters for the subcategory of H35.31 are:
0 - stage unspecified
1 - early dry stage
2 - intermediate dry stage
3 - advanced atrophic without subfoveal involvement advanced dry stage
4 - advanced atrophic with subfoveal involvement
The new codes are as follows:
H35.311 Nonexudative age-related macular degeneration, right eye
H35.312 Nonexudative age-related macular degeneration, left eye
H35.313 Nonexudative age-related macular degeneration, bilateral
The 7th character required for the subcategory of H35.32 are:
0 - stage unspecified
1 - with active choroidal neovascularization
2 - with inactive choroidal neovascularization with involuted or regressed neovascularization
3 - with inactive scar
The new codes are as follows:
H35.321 Exudative age-related macular degeneration, right eye
H35.322 Exudative age-related macular degeneration, left eye
H35.323 Exudative age-related macular degeneration, bilateral
Central retinal vein and branch retinal vein occlusion (CRVO and BRVO) codes were changed to add new 7th characters and these, too, are different 7th characters. Read these sections of the ICD-10-CM tabular codes carefully to ensure you understand the application of these 7th character designations.
ICD-10-CM added a new Amblyopia suspect code and expanded the post-operative complication codes. Orbital floor fracture coding was also changed. You should review these new expanded sections.
These new codes took effect on October 1, 2016. Carefully review any private insurers’ websites and/or bulletins to determine if they did implement these changes on October 1, 2016, to avoid claim denials.
There is an AOA recorded webinar you can listen to on these changes along with some other documents posted to the AOA Coding website. The entire summary of changes to ICD-10-CM can be reviewed and downloaded from the CDC website.
Dr. Rebecca Wartman attended The University of the South (B.A. Psychology) and University of Missouri St Louis School of Optometry. She is in private practice caring for nursing facility patients in western North Carolina. She writes and lectures on insurance and coding issues as well as Long Term Care Eye Care. She serves as National Director of Clinical Operations- Optometry for Trident Mobile Clinical Services, currently serves on the NCSOS Third Party Committee and American Optometric Association Third Party Center Executive Committee, and is the AOA advisor to CPT® Editorial Panel.