Q&A: Reporting glaucoma in ICD-10-CM

Q: We have an elderly patient admitted in our hospital who is also presenting with glaucoma. Since we don’t report glaucoma on a regular basis, can you explain any background, guidelines, or tips for reporting glaucoma in ICD-10-CM?

A: Glaucoma is a group of eye conditions that damage the optic nerve, the health of which is vital for good vision. This damage is often caused by abnormally high pressure in the eye.

Per the ICD-10-CM Official Guidelines for Coding and Reporting, assign as many codes from category H40.- (glaucoma) as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage. Seventh characters for codes identifying types of glaucoma are assigned for the stage:

• 0, stage unspecified
• 1, mild stage
• 2, moderate stage
• 3, severe stage
• 4, indeterminate stage

So, with this in mind, some of the codes that could be reported for glaucoma include:

• H40.062, primary angle closure without glaucoma damage, left eye
• H40.10X3, unspecified open-angle glaucoma, severe stage
• H40.10X4, unspecified open-angle glaucoma, indeterminate stage
• H40.1221, low-tension glaucoma, left eye, mild stage
• H40.1222, low-tension glaucoma, left eye, moderate stage
• H40.1411, capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
• H40.1412, capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage

Coders need to pay attention to glaucoma laterality and staging of the levels in each eye. When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage.

When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. Certain subcategories do not have laterality options, so coders should assign one code for each type and/or stage of glaucoma with the appropriate seventh character for the stage.

Editor’s note: Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, coding regulatory specialist for HCPro, a brand of Simplify Compliance LLC, in Middleton, Massachusetts answered this question.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.