Bb-gun Injury Has Bearing On Your Ophthalmology Coding

The reason why your patient is visiting is certainly important

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Question: We have a patient who came to us for a routine eye exam; however reported retinal damage from a BB-gun incident six years back. What would be the best option to code this? This is a new patient and I dont have any records which are old.

Answer: Until and 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 of the visit. If the patient made up his mind to see an optometrist owing to eye pain, eye pain (379.91, Pain in or around eye) or whatever the optometrist found that was the cause of the pain would be the diagnosis. If the eye pain is in fact the late effect of the BB-gun injury, you could go for 906.0 (Late effect of open wound of head, neck and trunk) as a secondary diagnosis.

"When you report late effects of an acute injury," instruct the IVD-9 guidelines, "code the residual problem/condition as the primary diagnosis and record the right late effects code as a secondary diagnosis. "In the above instance, 379.91 would be the primary diagnosis, whereas 906.0 would be the secondary diagnosis.

But: If this was indeed a routine exam, and the patient says no to any current complaints, you would have to report V72.0 (Examination of eyes and vision) as the diagnosis. Most carriers will not reimburse you for this visit unless the patient has vision insurance that covers routine exams.

by: Nancy Rose

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