The reason your patient is visiting is key.
Question: We have a patient who came in for a routine eye exam, but reported retinal damage from a BB-gun incident six years ago. What would be the best way to code this? This is a new patient, and I do not have any old records.
Answer: Unless the BB-gun injury six years ago has something to do with why the patient is there, it may not have any bearing on your coding. The diagnosis code always depends on the reason for the visit. If the patient decided to see an optometrist because of eye pain, eye pain (379.91, Pain in or around eye) — or whatever the optometrist found that was causing the pain — would be the diagnosis. If the eye pain is indeed the late effect of the BB-gun injury, you could report 906.0 (Late effect of open wound of head, neck and trunk) as a secondary diagnosis.
“When reporting late effects of an acute injury,” instruct the ICD-9 guidelines, “code the residual problem/condition as the primary diagnosis and record the appropriate late effects code as a secondary diagnosis.” In the above example, 379.91 would be the primary diagnosis, and 906.0 would be the secondary diagnosis.
However: If this was truly a routine exam, and the patient denies any current complaints, you would have to use V72.0 (Examination of eyes and vision) as the diagnosis. Unless the patient has vision insurance that covers routine exams, most carriers won’t reimburse you for this visit.
@ Ophthalmology Coding Alert (Editor: Jerry Salley, CPC).
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