Uveitis can be challenging in ophthalmology coding due to its variable presentation and associated conditions. Accurate coding is critical to ensure proper reimbursement and support the medical necessity of ongoing treatment and comanagement with other specialties.
This Q&A is designed to clarify common coding questions encountered when managing patients with uveitis.
Q: What ICD-10-CM codes are used to report uveitis?
A: Uveitis can affect different parts of the eye. Anterior uveitis involves the front part of the eye (such as the iris), intermediate uveitis involves the vitreous and pars plana, and posterior uveitis affects the retina and choroid. Panuveitis involves multiple areas, including the anterior chamber, vitreous, and retina or choroid.
Uveitis codes are found under 3 sections of the International Classification of Diseases (ICD-10) for Diseases of the eye and adnexa (H00-H59).
H20 (Iridocyclitis)
- H20.0 Acute and subacute iridocyclitis (H20.00-H20.059)
- H20.1 Chronic iridocyclitis (H20.10-H20.13)
- H20.8 Other iridocyclitis (H20.811-H20.829)
- H20.9 Unspecified iridocyclitis
H30-H36 Disorders of choroid and retina (H30-H36)
- H30 Chorioretinal inflammation (H30.001-H30.93)
- H35 Other retinal disorders (H35.00-H35.9)
H44.1 Other endophthalmitis
- H44.11 Panuveitis (H44.111-H44.119)
- H44.13 Sympathetic uveitis (H44.131-H44.139)
The “unspecified eye” diagnoses should not be used.
Q: Can I report both the uveitis diagnosis and an underlying systemic condition?
A: Yes. You should code both diagnoses. The systemic conditions D86.0 for sarcoidosis of the lung or M45.0 for ankylosing spondylitis provide essential context for determining medical necessity. Use the ocular diagnosis as the primary code and the systemic diagnosis as the secondary code.
Q: How do I determine whether to code uveitis as infectious or noninfectious?
A: The battery of lab and diagnostic testing ordered by the physician helps them determine whether there is an underlying disease. Only code uveitis as infectious if a confirmed infectious agent is documented in the medical record. If no specific infectious organism has been identified, the correct approach is to code it as noninfectious.
Q: What documentation pitfalls should we avoid in uveitis coding?
A: As with all documentation, specificity is essential—not only for the diagnosis code, but in the exam and impression/plan. Since there are different treatment options depending on where the uveitis exists in the eye and whether an underlying condition must also be considered in the treatment plan, clear documentation to support the diagnosis code is imperative.
The chart documentation and coding should align with clinical findings. For treatment options, it is essential to know payor policies, particularly in chronic inflammatory conditions such as uveitis, where multiple systems might be affected and the treatment options could involve step therapy. RP
