ICD-10 Coding for Bilateral Glaucoma(H40.113_, H40.123_)
Complete ICD-10-CM coding and documentation guide for Bilateral Glaucoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Glaucoma
H40.1-H40.9Primary Range
Glaucoma
This range includes all types of glaucoma, including bilateral cases, with specific codes for laterality and stage.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H40.113_ | Bilateral primary open-angle glaucoma | Use when both eyes have primary open-angle glaucoma of the same stage. |
|
| H40.123_ | Bilateral low-tension glaucoma | Use when both eyes have low-tension glaucoma of the same stage. |
|
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 bilateral glaucoma
Essential facts and insights about Bilateral Glaucoma
Primary ICD-10-CM Codes for glaucoma bilateral
Decision Criteria
clinical Criteria
- Both eyes must have the same type and stage of glaucoma.
Applicable To
- Primary open-angle glaucoma affecting both eyes
Excludes
- Secondary glaucoma
Clinical Validation Requirements
- Cup-to-disc ratio ≥0.7 bilaterally
- Symmetrical visual field loss
Code-Specific Risks
- Ensure stage is documented to avoid unspecified coding.
Coding Notes
- Document the stage and type clearly to avoid unspecified codes.
H40.123_ - Bilateral low-tension glaucoma
Use when both eyes have low-tension glaucoma of the same stage.
Applicable To
- Low-tension glaucoma affecting both eyes
Excludes
- High-tension glaucoma
Clinical Validation Requirements
- IOP ≤21 mmHg with characteristic optic nerve damage in both eyes
Coding Notes
Document IOP and optic nerve findings to support coding.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Glaucoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H40.113_.
Impact
Clinical: Leads to incomplete clinical records., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Use templates that prompt for stage documentation., Regular training on documentation standards.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Decreases the accuracy of clinical data.
Mitigation Strategy
Document the type, laterality, and stage to use specific codes.
Impact
Frequent use of unspecified codes can trigger audits.
Mitigation Strategy
Ensure complete documentation of type, laterality, and stage.
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 Bilateral Glaucoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Glaucoma
Use these documentation templates to ensure complete and accurate documentation for Bilateral Glaucoma. These templates include all required elements for proper coding and billing.
Bilateral primary open-angle glaucoma, moderate stage
Specialty: OphthalmologyRequired Elements
- Diagnosis
- Laterality
- Stage
- Findings
- Treatment Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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