Documentation training and education is crucial to correctly code blindness and low vision conditions. Category-level tabular instruction at H54.- (Blindness and low vision) requires you to “code first” the underlying cause of the patient’s blindness and low vision. Most codes within this category require a high level of detail in the category of vision loss, whether one or both eyes are affected, and to what degree.
Codes for blindness and low vision conditions are found in Chapter 7 (Diseases of the Eye and Adnexa), specifically within the section “Visual disturbances and blindness” where categories H53.- (Visual disturbances) and H54.- are housed. You will find more specificity if you scroll down and look under additional terms that are indented under the main term, such as those specifying laterality, when there is a distinction between visual acuity in different eyes, and when blindness is defined in legal terms.
Get Sequencing Right
While many causes of blindness may indeed be diseases of the eye, there are also other causes. For example, blindness can be caused by injury and traumas, as well as neoplasms. Codes for these conditions are found in Chapter 19 (injury, poisoning, and certain other consequences of external causes), and Chapter 2 (Neoplasms), respectively. Glaucoma codes are separated by type, stage, and affected eye. Patients can have different types and stages of glaucoma in different eyes, with varying levels of visual impairment. This may require different codes for each eye, depending on the circumstances.
For example, a total of three codes would be required to completely capture a patient with severe stage primary open-angle glaucoma in the left eye, and moderate stage primary open-angle glaucoma in the right eye, with resultant category 2 low vision in the right eye and category 4 blindness in the left:
Download our Tips for Coding Blindness & Low Vision
The Importance of Documentation
Ask yourself the following questions when perusing documentation to assign the most specific code for the patient’s blindness and low vision:
Keep in mind that less detail will result in a less specific code. If there’s not enough documentation to know the answers to those three questions, the FY2018 coding guidelines contain a new section on how to assign codes in the following circumstances:
Karen Tibbs, RN, HCS-D, COS-C
Karen Tibbs, RN, HCS-D, COS-C, is a Quality Manager in OASIS and Coding Services for McBee. She has a Master of Science Degree in Health Care Quality and has worked in the home health industry for more than 21 years.
For more information, check out Karen Tibbs article in the December 2017 Issue of Diagnosis Coding Pro for Home Health.