Check Out These Tips: Coding Blindness and Low Vision

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:

  • H40.1123 (Primary open-angle glaucoma, left eye, severe stage), H40.1112 (Primary open-angle glaucoma, right eye, moderate stage), and H54.1224 (Low vision right eye category 2, blindness left eye category 4).

Download our Tips for Coding Blindness & Low Vision

Tips for Coding Blindness and 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:

  1. Is the visual impairment limited to one eye or both?
  2. If the visual impairment is limited to one eye, which eye is affected?
  3. What is the level of impairment (such as category 1 or category 5) for each eye?

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:

  • If “blindness” or “low vision” of both eyes is documented but the visual impairment category is not documented, assign code H54.3, Unqualified visual loss, both eyes.
  • If “blindness” or “low vision” in one eye is documented but the visual impairment category is not documented, assign a code from H54.6-, Unqualified visual loss, one eye. For example, H54.62 corresponds to Unqualified visual loss, left eye, normal vision right eye.
  • If “blindness” or “visual loss” is documented without any information about whether one or both eyes are affected, assign code H54.7, Unspecified visual loss.

About The Contributor

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.