Focus on Glaucoma

COUNTDOWN TO ICD-10 comes to glaucoma

What to expect and how to prepare.

By René Luthe, Senior Associate Editor

ICD-10 will be upon ophthalmologists this fall, and glaucoma specialists won’t be spared the sturm und drang it promises to bring. In this installment of our on-going series on ICD-10, Ophthalmology Management spoke with those who have seen the new system up close and personal to find out what changes you can expect to find, as well as how to ensure your coding passes (reimbursement) muster.

THE ICD-10 DIFFERENCE

New requirements means more codes

The glaucoma family of codes is located in chapter 7 of the new ICD-10 book, and runs from H40 to H42. Michael X. Repka, MD, medical director for government affairs at the American Academy of Ophthalmology, reports that while the good news is that ICD-10 features no new parent codes that do not exist in ICD-9 (this year), ophthalmologists will still find plenty of new material to challenge them. The introduction of two new indicators means that physicians will be dealing with more, and more specific, codes.

Laterality is one of the main differences that distinguish ICD-10 from ICD-9. While not all of the glaucoma diagnosis codes require it, many do mandate the physician note whether the diagnosis is for right eye, left or bilateral. Laterality is indicated in the sixth digit of the new coding system.

The other addition is glaucoma severity staging. Optional at present, staging will be mandatory under ICD-10; there will be no way to code correctly without indicating glaucoma stage. It’s denoted in the seventh, or last digit, of the code. Staging is based on a combination of optic nerve condition and visual fields. The choices for staging are 0, 1, 2, 3 and 4.

Glaucoma through the stages

One indicates mild glaucoma, 2 is moderate, 3 severe and 4 indeterminate. As for 0? “Unspecified,” says Kevin Corcoran, COE, CPC, CPMA, FNAO, president of Corcoran Consulting Group, which specializes in coding and reimbursement issues for eye-care practices. “In other words, the doctor didn’t specify in the medical record, the information is missing,” he says. These staging number are not changing in ICD-10, Mr. Corcoran notes.

As for what “mild” or moderate should mean under ICD-10, Cynthia Mattox, MD, New England Eye Center, Boston, and Patient Care Committee Chair at the American Glaucoma Society, provides some guidance based on the definitions developed by the AGS workgroup:

• 1 mild: No visual field loss on white-on-white standard perimetry, but the optic nerve looks glaucomatous.

• 2 moderate: Optic neuropathy consistent with glaucoma, plus visual field loss in one hemifield only, “and not within 5° of fixation, which are the four central spots on visual field,” Dr. Mattox explains.

• 3 severe: A glaucomatous optic disk plus visual field loss in two hemifields. Alternately, if the visual field loss is limited to one hemifield, it involves the central 5°.

• 4 indeterminate: Either the doctor cannot determine the nature of the visual field loss, or the patient has not been tested yet, or the patient performed very poorly on the visual field test so the physician cannot rely on the test results to arrive at a diagnosis.

Each stage, Dr. Mattox emphasizes, is recorded as a digit in the code. Together, the two new requirements of laterality and staging mean that “the number of codes is exponentially greater than it used to be,” Dr. Mattox says.

Dr. Repka notes that third-party payers, however, may not insist on the staging indicator specificity. “The payer always has that discretion, and it would make the new coding a little bit easier for practices,” he says.

HOW CODES ARE STRUCTURED

Swapping two codes for one

The difference between ICD-9 and ICD-10 glaucoma diagnosis codes is this, explains Mr. Corcoran: You transition from two shorter codes to one longer, more descriptive code.

“In ICD-9, the physician records a diagnosis code for glaucoma. An example would be 365.10 open-angle glaucoma,” Mr. Corcoran says. It is comprised of just five digits within ICD-9. “Prior to October 1, 2014, you would add the stage of glaucoma you found, let’s say mild, and choose a second code, 365.71. So the first code is the type of glaucoma; the second code is how bad,” he says. It is the combination of two codes in ICD-9 that is completely descriptive.

“ICD-9 had two codes to accomplish what is done in ICD-10 with one, longer code,” he says.

What it should look like

Both laterality and staging are indicated in specific digits of the ICD-10 code — the sixth and seventh digits, respectively. So what should a correct code — one that CMS will accept for payment — look like?

Sue Vicchrilli, COT, OCS, coding executive with the American Academy of Ophthalmology, cites the example of a capsular glaucoma with pseudoexfoliation of the lens, mild stage in the right eye. “The chapter header for glaucoma is H40. ICD-10 code H40.14 indicates capsular glaucoma with pseudoexfoliation of lens, but because greater specificity is required, that is not a payable code.”

To obtain payment, the eye(s) must be identified, Ms. Vicchrilli explains. H40.141 indicates the right eye, H40.142 indicates the left eye and H40.143 indicates both. “When indicating the stage another 1 must be added as the seventh digit indicating mild stage,” she says. The final payable ICD-10 code is H40.1411

The placeholder

Some codes will not have a sixth digit for laterality, Ms. Vicchrilli points out. For example, primary open-angle glaucoma is H40.11 — the sixth digit is missing. In this case, the physician should place an ‘X’ in the sixth digit as a placeholder, and then append the seventh digit for the glaucoma stage. “Thus open-angle glaucoma, mild stage would be H40.10X1,” Mr. Corcoran explains, “and not H40.101.” In future editions of the ICD-10 handbook, it’s likely that laterality will be added for open-angle glaucoma for greater specificity.

INEVITABLE GLITCHES

Staging codes not universal

Don’t expect perfect continuity throughout the family of diagnostic codes, Ms. Vicchrilli warns. Not every glaucoma code specifies laterality or staging. “For example, if you need to code anatomical narrow angle, steroid responder, ocular hypertension or primary-angle closure without glaucoma damage — those four conditions have a 1, 2 and a 3 to indicate the relevant eye. But none of those require staging codes,” Ms. Vicchrilli explains.

For 2014, in fact, one of the most common glaucoma diagnostic codes does not have a laterality option in the ICD-10 book. Primary open-angle glaucoma does not require a laterality digit in the new coding system. Nor do the codes used for unspecified open-angle glaucoma, primary angle-closure glaucoma, unspecified primary angle-closure glaucoma, other specified glaucoma, or unspecified glaucoma.

“Everyone is going to wonder how in the world this happened,” Dr. Mattox says. “We were told by the ICD committee that it was something that happened years ago, and we were not able to implement any changes until the 2015 version of ICD-10 comes out.” For codes without laterality that require a staging level, you should code the stage for the most severely affected eye, Dr. Mattox adds.

Some codes harder to find

Additionally, some glaucoma diagnostic codes that had single codes under ICD-9 are no longer in the glaucoma-specific codes of ICD-10, according to Dr. Mattox. Neovascular glaucoma is one. “There’s no specific glaucoma with vascular disorder code,” she explains. “So what you have to do is use “glaucoma with ocular disorder” plus then add whatever the ocular disorder is, such as central retinal vein occlusion, or proliferative diabetic retinopathy.”

Those codes are found in other sections of ICD-10, not in the glaucoma chapter.

EHR AS CODING AID

Many incorporate ICD-10

If the above sounds daunting, Dr. Repka says that glaucoma specialists already using an EHR system should have an easier transition to ICD-10. He expects that many EHR software systems have already incorporated the ICD-10 codes. “I work in an Epic environment (Epic Systems, Verona, Wis.) and I already see the new codes are there,” he says. “Instead of putting numbers in, you type partial text and it shows you possible selections. All of the laterality and severity selections are already there. Although they are not being submitted as part of an ICD-9-supported claim now, you are actually choosing them.”

Dr. Mattox, however, cautions against believing that all EHRs will painlessly solve all your coding difficulties with the new system. “EHR is a starting point, but I would be pretty shocked if most electronic record systems have ICD-10 down pat right now,” she says. “Maybe it will be there by October, but who knows?”

Help is on its way

But if EHR is of indeterminate value in navigating the new coding system, associations such as the Academy and American Glaucoma Society are busy creating the aids ophthalmologists will need. The Academy is offering live and online “Conquering ICD-10” courses, Ms. Vicchrilli reports, to assist physicians, administrators, technicians and billers and coders transition to the new diagnosis system. The live courses consist of three hours devoted to the new coding system, and a fourth hour for an update on coding changes for 2014.

Another Academy offering is a web conference narrated by an ophthalmologist: “90 Minutes to Conquering ICD-10” is available online at the AAO store and includes an explanation of terminology, usage guidelines, and step-by-step implementation.

And for old-fashioned types, there’s guidance in book form: the 2104 ICD-10 for Ophthalmology Book. “Ophthalmology is the only specialty in medicine that has developed its own ICD-10 book,” says Ms. Vicchrilli, and an ophthalmologist wrote that book. “At the beginning of the book, we have already converted the most frequently used diagnostic codes to ICD-10,” she says. “So we’ve already done a significant amount of the work for you.”

At the AGS annual meeting at the end of this month, Ms. Vicchrilli will conduct a session on ICD-10 coding.

Dr. Mattox recommends consulting one of these aids and then starting to practice a little bit now in order to get the feel for what ICD-10 involves. “A lot of things you have to physically look up,” she warns. “I think some of it is going to be easier than we think and other pieces are going to be more difficult.” OM