Diagnosis Coding - Vision

Important Note:

Effective January 1, 2022, HMSA has partnered with EyeMed for routine vision services for the following lines of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees.
Non-routine vision services remain under our medical benefit and will be processed as such.
For more information, please visit EyeMed at www.eyemedinfocus.com.

Incorrect diagnosis coding is a common reason claims processing is delayed. Your adherence to the guidelines below will help ensure that your claims are processed quickly and accurately.

In addition, diagnosis codes are a key data type used by HMSA to identify trends in use. For this reason, it is important that diagnoses be accurately coded on the claims you submit to HMSA.

Correct diagnosis coding begins with selecting the appropriate diagnosis code(s) from the most recent edition of the ICD-9-CM/ICD-10-CM coding manual. HMSA accepts ICD-9-CM diagnosis codes entered to the fifth position and ICD-10-CM diagnosis codes entered to the seventh position. The following guidelines will help you to choose the most appropriate code:

• Select the most specific diagnosis code available to describe the patient's condition. For example, do not select degeneration of macula and posterior pole when the patient has cystoid macular degeneration or toxic maculopathy. However, do not add zeros after the decimal to artificially create five positions.
• List a secondary diagnosis only when it has a bearing on the patient's current medical condition and treatment. For example, if a patient's hypertension complicates or otherwise affects a provider's treatment of the eye, both diagnoses should be listed on the claim. The diagnosis most closely linked to the patient's current complaint should be listed in the primary position.
• Do not list conditions for which the patient was previously treated and has since recovered, or that have no bearing on the patient's current complaint and treatment.

If you do not have a current copy of the ICD-9-CM/ICD-10-CM manual, it is advised that you purchase one and obtain an updated version a minimum of every two years. Please refer to Resource Books or information on ordering the current edition of the manual.

Claims Filing Information

In addition to selecting the most appropriate diagnosis for your patient, it is important to place the codes in Block 21 of the CMS 1500 claim form correctly. If the supporting reference number (1, 2, 3 or 4) from Block 21 is not entered in Column 24E, the primary diagnosis will be used to support all of the services rendered, which may result in benefits being denied or processed incorrectly for individual procedures. Please refer to the following examples for the appropriate use of diagnosis code reference numbers.

Example

If an established patient was seen by the optometrist because the patient's right eye was red and irritated from debris two days earlier (medical vision care service), the claim might be coded as follows:

• The primary diagnosis would be ICD-9-CM 372.03/ICD-10-CM H10.021 (other mucopurulent conjunctivitis).
• An appropriate secondary diagnosis would be ICD-9-CM 871.6/ICD-10-CM S05.51xA (penetration of eyeball with (nonmagnetic) foreign body).
• A cause of injury code should also be used in the last position to explain the cause of the injury. An appropriate cause of injury code would be ICD-9-CM E914 (foreign body accidentally entering eye and adnexa)/ICD-10-CM T15.01xA (foreign body in cornea, right eye, initial encounter). A brief notation should be made in Block 19, explaining how the injury occurred (e.g., sawdust got in patient's eye while cleaning at home).
• Reference numbers (1, 2, 3 or 4) must be placed in Column 24E to correlate the diagnoses codes with the appropriate codes for procedures, services or supplies in Column 24D.

Revision History