Q&A Code it or not??

[Linda Charlwood]

Ok so I am coding lot's of cases today.......here is another.

Pt comes to the ER for loss of vision in LT eye for the past 4 days. PT was seen previously (chat doesn't say when) at another hospital and diagnosed w/retinal detachment by an opthamologist but PT doesn't have ins so didn't get treated.

Now he presents with loss of vision - still no ins.
There is no opthamologist available to see PT and treat him. ER dr reports he will continue to try and get an eye surgeon for the PT and call the PT back if he can obtain an appointment. PT realizes he may lose his vision.
PT is discharged.

History - Diabetes Mellitus T1, hypertension.
Current meds - for high blood pressure and for diabetes.

Diagnosis- Detached Retina

So do you code the DX as retinal detachment 361.9 and 250.01

or even though the DX doesn't actually say diabetes with opthalmic manifestations - still code it as 361.9, 250.51, 362.01, and 401.9 ?

I think 361.9, 250.51, 362.01. NO? Yes?

Thanks!!
Linda

 

[Dori]

Ok so I am coding lot's of cases today.......here is another.

Pt comes to the ER for loss of vision in LT eye for the past 4 days. PT was seen previously (chat doesn't say when) at another hospital and diagnosed w/retinal detachment by an opthamologist but PT doesn't have ins so didn't get treated.

Now he presents with loss of vision - still no ins.
There is no opthamologist available to see PT and treat him. ER dr reports he will continue to try and get an eye surgeon for the PT and call the PT back if he can obtain an appointment. PT realizes he may lose his vision.
PT is discharged.

History - Diabetes Mellitus T1, hypertension.
Current meds - for high blood pressure and for diabetes.

Diagnosis- Detached Retina

So do you code the DX as retinal detachment 361.9 and 250.01

or even though the DX doesn't actually say diabetes with opthalmic manifestations - still code it as 361.9, 250.51, 362.01, and 401.9 ?

I think 361.9, 250.51, 362.01. NO? Yes?

Thanks!!
Linda

I'm thinking that since he wasn't diagnosed at 'this' ER, I'd probably code for vision loss (369.9) , diabetes t1 (250.1 because documentation doesn't state it's linked to the retinal detachment), and essential hypertension because, again, in this example, there is no further documentation to further describe the hypertension. I'd also code for long term insulin use (V58.67). With this limited information from the record, I wouldn't be comfortable "assuming" the possible relationship between the eye and the diabetes and also linking the hpertension to the diabetes even though we know there 'could' be a very possible link.

 

[Carolyn Heath]

I would code the retinal detachment (361.9), diabetes T1 (250.10), long term insulin use (V58.67), and hypertension (401.9) because the pt is still taking meds for the high blood pressure. I don't see in the record that the retinal detachment is related to diabetes.

 

[Ruth Sheets]

This was covered in the May 2013 Q&A Webinar. Here is a video on the subject:

https://www.cco.us/coding-detached-retina-video/