The New Year has always been associated with change—and 2015 is going to be one filled with it. The area of medical coding and compliance is always subject to changes that are difficult to understand, let alone apply to clinical management in your practices. 

Review of Optometry recognizes this, and is updating the format of our venerable department previously known as “Coding Abstract.” The column is now called “Coding Connection,” intended to provide you with content that’s more closely connected to the featured monthly clinical topics. Why? Because clinical decisions and coding responsibilities go hand in hand. To truly master the patient care of any given condition, we also need a good command of the documentation and billing aspects that enable it.

Our format is going to change as well. In some months, the coding coverage will come in the form of a sidebar integrated into a chosen clinical feature that month. Other times, it’ll be a standalone column like this one. Either way, our goal is to make the medical coding and compliance issues immediately applicable to the clinical content and situations you encounter on a daily basis, in a presentation that will be seamless as you read the magazine or web site each month. 

Coding for Anterior Uveitis
For example, one of the clinical features in this issue concerns the management of anterior uveitis or iritis (“ Practical Pearls for Anterior Uveitis."). As we know, iritis can be acute or chronic, depending on the cause of the in-flammatory event. Coding for iritis is fairly simple, yet it is critical to maintain a proper sequence of events in the medical record. 

In other words, was the iritis the primary cause of the office visit or was it a sequelae of another clinical presentation? 

White blood cells in the anterior chamber, seen here, are a characteristic sign of anterior uveitis, so this presentation doesn't usually require special tests for diagnosis. Photo: Kyle D. Dohm, OD.

Be precise in your recording of the chief complaint as well as the secondary reasons that the patient is in your office that day. Get in the habit of recording specifics such as the circumstances (injury or traumatic) and the laterality (right eye, left eye, both eyes) as this will be required for ICD-10. 

The code for a typical office visit is 920X2 or the appropriate level 992XX code based upon the relevant history, physical exam and related medical decision making. If the iritis is caused by a systemic condition, keep in mind that both the ICD-9 and the forthcoming ICD-10 require that the systemic diagnosis be primary and the ocular sequelae are secondary when filing the claim with a medical carrier. 

It’s rare that the management of iritis requires special ophthalmic tests such as anterior segment photos or OCT, unless you can specifically demonstrate the medical necessity for the specific procedure and how it aided you in getting a better clinical outcome.

Here’s to starting strong in 2015: Out with the old and in with the new! Our format and presentation may change, but one thing that you can always count on is that I’ll continue to bring you solutions to all of the core coding and medical record compliance issues that many of you face in day-to-day practice, just as I have since this column started nearly a decade ago. 

You can still reach me here at Review, just at a new email address:  [email protected]. I look forward to hearing from you.