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Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
Comprehensive ICD-10-CM coding guidelines for glaucoma, blindness, and visual impairment documentation
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Section a: Glaucoma
Assigning Glaucoma Codes
Assign as many codes from category H40, Glaucoma, as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage.
The coding process requires careful attention to three key elements: the specific type of glaucoma diagnosed, which eye or eyes are affected, and the documented stage of disease progression.
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Bilateral glaucoma with same type and stage
When bilateral code exists
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.
When bilateral code does not exist
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, and H40.20) report only one code for the type of glaucoma with the appropriate seventh character for the stage.
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Bilateral glaucoma stage 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.
01
Different types without laterality distinction
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, and H40.20), assign one code for each type of glaucoma with the appropriate seventh character for the stage.
02
Same type, different stages without laterality
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 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.
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Patient admitted with glaucoma and stage evolves during the admission
Critical Coding Rule:
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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Indeterminate stage glaucoma
Assignment 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.
Seventh Character "4"
Indeterminate Stage
Used when the stage cannot be clinically determined based on available documentation and examination findings.
Seventh Character "0"
Unspecified Stage
Used when there is no documentation regarding the stage of the glaucoma in the medical record.
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Section b: Blindness
Visual Impairment Coding Guidelines
Both Eyes Affected
If "blindness" or "low vision" of both eyes is documented but the visual impairment category is not documented, assign code H54.3, Unqualified visual loss, both eyes.
One Eye Affected
If "blindness" or "low vision" in one eye is documented but the visual impairment category is not documented, assign a code from H54.6-, Unqualified visual loss, one eye.
Unspecified Laterality
If "blindness" or "visual loss" is documented without any information about whether one or both eyes are affected, assign code H54.7, Unspecified visual loss.
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Scenario Examples for ICD Chapter-7 Guidelines
The following practical scenarios demonstrate the application of Chapter 7 coding guidelines in real-world clinical documentation situations.
Scenario 1: Bilateral Same Stage
Patient presents with primary open-angle glaucoma, bilateral, both eyes documented as moderate stage. Code once with bilateral designation and seventh character for moderate stage.
Scenario 2: Different Stages
Patient has primary open-angle glaucoma: right eye mild stage, left eye severe stage. Assign separate codes for each eye with appropriate seventh characters.
Scenario 3: Stage Progression
Patient admitted with mild stage glaucoma that progresses to moderate stage during hospitalization. Code to the highest stage (moderate) documented during admission.
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Additional Scenario Examples
Scenario 4: Indeterminate Stage
Patient with glaucoma where clinical examination cannot determine the stage due to other ocular conditions. Use seventh character "4" for indeterminate stage based on clinical documentation.
Scenario 5: Unspecified Stage
Documentation states "patient has glaucoma" with no mention of stage or severity. Use seventh character "0" for unspecified stage due to lack of documentation.
Scenario 6: Visual Loss Documentation
Patient chart notes "visual loss" without specifying which eye(s) or category of impairment. Assign H54.7, Unspecified visual loss.
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