ICD-10 Coding for Abnormal Vision(H54.3, H54.2)
Complete ICD-10-CM coding and documentation guide for Abnormal Vision. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Vision
H53-H54Primary Range
Visual disturbances and blindness
This range covers all codes related to visual disturbances and degrees of blindness, which are central to abnormal vision diagnoses.
Encounter for examination of eyes and vision
These codes are used for vision screenings and encounters with abnormal findings, often ancillary to primary vision impairment diagnoses.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H54.3 | Unqualified bilateral vision loss | Use when both eyes have significant vision loss without specific categorization. |
|
| H54.2 | Low vision, both eyes | Use for moderate vision impairment in both eyes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal vision
Essential facts and insights about Abnormal Vision
Primary ICD-10-CM Codes for abnormal vision
Decision Criteria
clinical Criteria
- Visual acuity less than 20/200 in both eyes
Applicable To
- Bilateral blindness
Excludes
- Blindness NOS (H54.0)
Clinical Validation Requirements
- Documented visual acuity less than 20/200 in both eyes
Code-Specific Risks
- Risk of using without specifying acuity levels
Coding Notes
- Ensure documentation of visual acuity and any underlying causes.
H54.2 - Low vision, both eyes
Use for moderate vision impairment in both eyes.
Applicable To
- Moderate vision impairment
Excludes
- Blindness, both eyes (H54.3)
Clinical Validation Requirements
- Documented visual acuity between 20/70 and 20/200 in both eyes
Coding Notes
Document specific visual acuity measurements.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Vision to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H54.3.
Impact
Clinical: Impacts treatment decisions, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Always specify which eye is affected, Use templates that prompt for laterality
Impact
Reimbursement: May lead to reduced reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases the accuracy of health records.
Mitigation Strategy
Always document and code the specific level of vision impairment.
Impact
Audits may focus on the specificity of vision impairment documentation.
Mitigation Strategy
Ensure all documentation includes specific acuity measurements and laterality.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Vision, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Vision
Use these documentation templates to ensure complete and accurate documentation for Abnormal Vision. These templates include all required elements for proper coding and billing.
Vision Impairment Assessment
Specialty: OphthalmologyRequired Elements
- Visual acuity measurements
- Pupil examination results
- Fundus examination findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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