Glaucoma

One of the leading causes of blindness in older individuals is glaucoma, so in this edition of “In the kNOW”, we’ll discuss coding for this serious condition.  First, however, let’s get a better understanding of the disease.  In glaucoma, the optic nerve is damaged which results in loss of vision.  This is often the result of increased pressure within the eye due to a buildup of aqueous humor.  The increase in fluid could be a result of poor drainage through the trabecular meshwork or overproduction.  The loss of vision that occurs with glaucoma is irreparable, and there is no cure for glaucoma.  However, early diagnosis of the condition can help prevent or minimize vision loss.  This is one reason why regular ophthalmologic appointments are so important as the vision loss with glaucoma can be insidious, worsening slowly without the patient realizing there is a problem.  Without proper treatment, blindness will result from glaucoma. 

ICD-10-CM addresses glaucoma in the Official Coding Guidelines.  The first guideline related to glaucoma focuses on the fact that there are many types of glaucoma (low-tension, open-angle, angle-closure, etc.), and that to accurately reflect the patient’s condition, coding professionals should assign as many codes from the H40 category as necessary to convey the patient’s diagnosis.  The codes in the H40 category capture the type and stage of the glaucoma, along with the affected eye.

The next guideline revolves around coding for bilateral glaucoma.  When the type and stage of the glaucoma is the same in both eyes, if there is a code for “bilateral”, then that is the code that should be assigned.  However, in the circumstance that the type and stage of the glaucoma are the same in both eyes, but there is no code that reflects “bilateral”, (for example, in subcategories H40.10 and H40.20), then coding professionals are instructed to assign only ONE code.  In both circumstances noted here, the seventh character assigned will indicate the stage of the glaucoma.

Bilateral glaucoma coding continues to be addressed in the third guideline.  While the second guideline dealt with same type and stage of glaucoma, this guideline addresses coding when there is bilateral glaucoma but with different type or stage.  When such is the case, a code should be assigned for each eye based on glaucoma type and stage for the specific eye.  When coding bilateral glaucoma of different types, if laterality is not distinguished in the code (for example, in subcategories H40.10 and H40.20), coding professionals are required to assign one code for EACH type of glaucoma using the seventh character to reflect the stage.  When coding bilateral glaucoma of different stages but the same type, if laterality is not distinguished in the code (for example, in subcategories H40.10 and H40.20), the instruction is to assign a code for the type of glaucoma for each eye using the appropriate seventh character to capture the stage.

The fourth glaucoma guideline provides instruction on how to code glaucoma for an inpatient whose condition has worsened during their stay.  In this instance, the glaucoma code assigned should reflect the highest stage that was documented during the admission.

The final guideline related to glaucoma provides clarification on the term “indeterminate” stage.  Coding “indeterminate” stage for glaucoma means that clinical determination of the glaucoma stage cannot be made by the provider.  It is important for coding professionals to be mindful of the distinction between “indeterminate” and “unspecified” stages.  “Unspecified” is assigned for a glaucoma stage only when there is no documentation at all regarding the glaucoma stage.   

Review of the guidelines will enable coding professionals to correctly apply codes for glaucoma conditions.

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Modifiers

This edition of “Spotlight on CPT” will focus on modifiers.  Let’s begin by identifying what a modifier is.  A modifier, in CPT, is comprised of two-characters which acts to supply more detail about a procedure without altering the actual definition of the procedure itself.  For example, modifier 50 will indicate that the procedure being modified was performed bilaterally.  Modifiers are appended to a CPT procedure code with a hyphen.  Look at code 64721-50.  64721 indicates a carpal tunnel release procedure was performed; modifier 50 tells that it was performed bilaterally.    

Modifiers can be found in the CPT manual in Appendix A and inside the front cover of the AMA publication.  Appendix A provides definitions for the modifiers which are only listed inside the cover of the manual.  Modifiers are categorized for use by providers or hospital outpatient facilities.  Additionally, as they relate to hospital outpatient facilities, there are Level I (CPT) modifiers and Level II (HCPCS) modifiers.  The Level II modifiers allow greater specificity when distinguishing between eyelids (E1, E4) or fingers/toes (T4, F5), capturing heart vessels (LD, RC), or establishing laterality (LT, RT).

It’s worth noting that the list of modifiers which apply to providers is different (longer) than the list for hospital outpatient facilities.  Most of the modifiers for hospitals overlap with the list for providers.  However, there are some modifiers which are specific only to hospital outpatient services.  These are modifiers 27, 73, and 74.  Modifier 27 indicates that there are multiple outpatient E/M encounters on the same date of service.  Modifiers 73 and 74 are used in hospital outpatient settings when a procedure is discontinued.  Modifier 73 is assigned if the procedure is discontinued before the patient receives anesthesia, whereas modifier 74 is used once anesthesia has been administered.  

One of the trickiest modifiers to apply is modifier 59.  This modifier is used to indicate a distinct procedural service.  This modifier is often assigned to bypass National Correct Coding Initiative (NCCI) edits.  Unfortunately, its indiscriminate use has led to fraud and abuse prompting the Centers for Medicare and Medicaid Services (CMS) to provide new modifiers to be used in place of modifier 59.  These X modifiers are not mandatory, leaving facilities and providers to make their own determination on whether or not to implement their usage.  The four X modifiers are as follows:

                XE-separate encounter

                XS-separate structure

                XP-separate provider

                XU-unusual non-overlapping service

It is valuable to understand what constitutes a distinct service.  CMS published “Modifier 59 Article” to clarify that term and provide relevant examples with rationales to assist coding professionals in appropriate application of this modifier.  The article can be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf

Physical status modifiers (P1-P6) are a specific subset of modifiers for use exclusively with anesthesia codes.  These modifiers give an indication of the patient’s overall health before surgery.  An example is physical status modifier P1 which means that the procedure is performed on a normal, healthy patient. 

Now, light has been shed on modifiers.

 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.