ICD-10 Coding for Bilateral Myopia(H52.13, H44.23)
Complete ICD-10-CM coding and documentation guide for Bilateral Myopia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Myopia
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H52.13 | Myopia, bilateral | Use for simple bilateral myopia without degenerative changes. |
|
| H44.23 | Degenerative myopia, bilateral | Use for high myopia (> -6D) with structural complications. |
|
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 myopia
Essential facts and insights about Bilateral Myopia
Primary ICD-10-CM Codes for myopia bilateral
Decision Criteria
clinical Criteria
- Refractive error ≤ -6D and axial length ≤ 26.5mm
coding Criteria
- No degenerative changes present
Applicable To
- Simple bilateral myopia
Excludes
- Degenerative myopia (H44.2-)
Clinical Validation Requirements
- Refractive error ≤ -6D
- Axial length ≤ 26.5mm
- No retinal pathology
Code-Specific Risks
- Misclassification if degenerative changes are present
Coding Notes
- Ensure documentation specifies bilateral involvement and absence of degenerative changes.
H44.23 - Degenerative myopia, bilateral
Use for high myopia (> -6D) with structural complications.
Applicable To
- High myopia with structural complications
Excludes
- Simple myopia (H52.13)
Clinical Validation Requirements
- Axial length > 26.5mm
- Presence of posterior staphyloma or myopic maculopathy
Coding Notes
Document axial length and specific retinal findings to support use.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for eye exam
Z00.5Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Myopia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H52.13.
Impact
Clinical: Inability to differentiate between simple and degenerative myopia., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials due to insufficient documentation.
Mitigation Strategy
Ensure axial length is measured and documented for all myopia cases.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use H44.23 when degenerative changes are present.
Impact
Using H52.13 instead of H44.23 for cases with degenerative changes.
Mitigation Strategy
Train staff on differentiating criteria and ensure thorough 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 Bilateral Myopia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Myopia
Use these documentation templates to ensure complete and accurate documentation for Bilateral Myopia. These templates include all required elements for proper coding and billing.
Routine eye examination for bilateral myopia
Specialty: OphthalmologyRequired Elements
- Chief complaint
- Visual acuity
- Refractive error
- Axial length
- Fundus exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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