2021 ASC Coding Tips: Cataracts and Glaucoma Documentation Improvement

By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Director of Coding

Strong documentation is the foundation for coding that leads to proper reimbursement. This month, we’ll discuss tips to make sure your ophthalmology cases are consistently meeting medical necessity requirements to avoid reimbursement delays.

Cataracts

Cataract removal with lens insertion is one of the most common ASC procedures. However, it is one of the most overlooked concerning documentation improvement.

Documenting to the highest level of specificity is a best practice for all specialties, but it can be the difference between payment and a denial for a cataract case. Documenting “cataract or visually significant cataract” is not enough information for a coder to assign anything other than an unspecified diagnosis. Ensure your providers know they need to document the type of cataract as well.

Here are some tips:

• Age-Related/Senile: Whether a cataract is age-related (i.e., senile) is an important detail to include as coders are not always allowed to assume a cataract is age-related based on a patient's age alone. Only nuclear, cortical, and subcapsular cataracts are automatically considered age-related.
• Mature vs. Hypermature: These different cataract conditions are important to distinguish in documentation. Documentation of only “mature cataract” results in assignment of H26.8 — "other specified cataract" — whereas hypermature is a Morgagnian cataract coded with H25.2-.
• Combined Forms: If a patient has two or more cataract types, such as nuclear and cortical, use the combined forms code: H25.81-. If the surgeon is only documenting “combined forms of cataract,” educate them regarding the requirement to specify age-related or include the specific types that are considered age-related.

Glaucoma

Glaucoma procedures are also common in the ASC setting and often performed in conjunction with cataract procedures. Just like a cataract, documentation of “glaucoma” without further specification results in an unspecified diagnosis code that won’t meet Medicare’s necessity requirements in most states and may cause delays with commercial claims as well.

Here are some tips:

• Open-Angle vs. Primary Open-Angle: While the documentation of an open-angle glaucoma and primary open-angle glaucoma is similar, the word "primary" makes all the difference for code selection. Open-angle glaucoma requires assignment of H40.10X- — "unspecified open-angle glaucoma" — whereas primary open-angle glaucoma is considered a more specified code: H40.11--.
• Glaucoma Stage: The stage of glaucoma is required for code selection to the highest level of specificity. Some Medicare LCDs will only cover glaucoma shunts for mild or moderate stages of glaucoma. Regardless of a patient's stage (mild, moderate, severe, or indeterminate), it’s important to include it in the operative report.