Coding & Reimbursement

Latest ICD-9-CM Updates Glaucoma Codes

By Suzanne L. Corcoran, COE

The changes to ICD-9-CM that took effect on October 1, 2011 are the last ones for this coding system; no further changes are contemplated because the United States will be taking up ICD-10-CM in 2013. These changes are implemented for Medicare and other payers, and they involve significant revisions to glaucoma codes.

Q. What changes should we expect?

A. Perhaps the most important change is coding to identify the severity or stage of glaucoma. These are supplemental codes reported along with the basic glaucoma code.

365.70 Glaucoma stage, unspecified

Glaucoma stage NOS

365.71 Mild stage glaucoma

Early stage glaucoma

365.72 Moderate stage glaucoma

365.73 Severe stage glaucoma

Advanced stage glaucoma
End-stage glaucoma

365.74 Indeterminate state glaucoma

An instruction to use the additional codes has been appended to many entries. For example:

365.10 Open-angle glaucoma

Use additional code to identify glaucoma stage (365.70 – 365.74)

Q. How are these stages determined?

A. Work groups from the American Glaucoma Society (AGS) coordinated with the American Academy of Ophthalmology to draft the new codes. All stages require glaucomatous optic neuropathy and stratification is based on visual field criteria.

According to a presentation by Cynthia Mattox, MD at the AGS meeting earlier in 2011, there are three stages: mild, moderate and severe.

365.71 Mild stage glaucoma – Optic nerve abnormalities consistent with glaucoma, but no visual field abnormalities on any visual field test. Or, abnormalities present only on short-wavelength automated perimetry or frequency doubling perimetry.

365.72 Moderate stage glaucoma – Optic nerve abnormalities consistent with glaucoma, and glaucomatous visual field abnormalities in one hemifield but not within five degrees of fixation.

365.73 Severe, advanced or end-stage glaucoma – Optic nerve abnormalities consistent with glaucoma, and glaucomatous visual field abnormalities in both hemifields, and/or loss within five degrees of fixation in at least one hemifield.

Q. When would we use 365.70 (unspecified stage) or 365.74 (indeterminate stage)?

A. Use 365.70 when there is no stage documented in the medical record. Use 365.74 for patients for whom you have not yet performed a visual field test, or patients who are incapable of testing successfully, or when you have an unreliable or uninterpretable test.

Q. What should we do about a glaucoma suspect exam?

A. Glaucoma suspect obviously does not have stages to document. Instead, coding will be based on risk factors. Codes 365.01 and 365.02 have been revised, and 365.05 and 365.06 have been added.

365.0 Borderline glaucoma [glaucoma suspect]

365.01 Open angle with borderline findings, low risk

Open angle, low risk (references to borderline IOP and optic disc cupping have been deleted)

365.02 Anatomical narrow angle

Primary angle closure suspect

365.05 Open angle with borderline findings, high risk

Open angle, high risk

365.06 Primary angle closure without glaucoma damage

“Low risk” for the open-angle patient is defined as having one or two risk factors, and “high risk” as having three or more risk factors. Risk factors include family history, race, elevated IOP, optic disc appearance and thin central corneal thickness.

For narrow-angle glaucoma patients, “primary angle closure suspect” (365.02) is a patient who has anatomical suspect, narrow angle. The new code 365.06 is to be used in the case of a patient with angle damage, but who does not have optic nerve damage.

Q. Why are these changes being made?

A. There are a number of reasons, including an enhanced ability to conduct health policy research. The new codes will allow claims-based information in order to better understand the patient populations. Over time, we may also see changes to coverage policies regarding the frequency of testing appropriate to the severity of disease. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.