ICD-10 Coding for Cataract Surgery(H25.01, H25.02)
Complete ICD-10-CM coding and documentation guide for Cataract Surgery. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cataract Surgery
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H25.01 | Age-related nuclear cataract, right eye | Use when cataract is age-related and affects the right eye, confirmed by clinical examination. |
|
| H25.02 | Age-related nuclear cataract, left eye | Use when cataract is age-related and affects the left eye, confirmed by clinical examination. |
|
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 cataract surgery
Essential facts and insights about Cataract Surgery
Primary ICD-10-CM Codes for cataract surgery
Decision Criteria
clinical Criteria
- Presence of nuclear sclerosis and patient-reported visual impairment
Applicable To
- Nuclear sclerosis
Excludes
- Congenital cataract (Q12.0)
Clinical Validation Requirements
- Slit-lamp examination showing nuclear sclerosis
- Patient reports glare and difficulty with night driving
Code-Specific Risks
- Ensure laterality is documented and coded correctly.
Coding Notes
- Ensure documentation supports the specific type and laterality of the cataract.
H25.02 - Age-related nuclear cataract, left eye
Use when cataract is age-related and affects the left eye, confirmed by clinical examination.
Applicable To
- Nuclear sclerosis
Excludes
- Congenital cataract (Q12.0)
Clinical Validation Requirements
- Slit-lamp examination showing nuclear sclerosis
- Patient reports glare and difficulty with night driving
Coding Notes
Ensure documentation supports the specific type and laterality of the cataract.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Presence of intraocular lens
Z96.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cataract Surgery to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H25.01.
Impact
Clinical: Impacts treatment planning and outcomes., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Always specify right or left eye in documentation., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts the accuracy of clinical data.
Mitigation Strategy
Ensure the specific type of cataract is coded when documented in the medical record.
Impact
Failure to document specific cataract type can lead to audit issues.
Mitigation Strategy
Use detailed templates and ensure thorough clinical documentation.
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 Cataract Surgery, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cataract Surgery
Use these documentation templates to ensure complete and accurate documentation for Cataract Surgery. These templates include all required elements for proper coding and billing.
Standard Cataract Surgery
Specialty: OphthalmologyRequired Elements
- Patient symptoms and visual acuity
- Type and laterality of cataract
- Surgical procedure details
- Post-operative care instructions
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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