ICD-10 Coding for Open-Angle Glaucoma, Moderate Stage(H40.11X2, H40.1132)
Complete ICD-10-CM coding and documentation guide for Open-Angle Glaucoma, Moderate Stage. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Open-Angle Glaucoma, Moderate Stage
H40.11X2-H40.1132Primary Range
ICD-10 codes for moderate stage open-angle glaucoma
These codes are used to classify moderate stage open-angle glaucoma based on laterality and severity.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H40.11X2 | Unilateral primary open-angle glaucoma, moderate stage | Use when moderate stage glaucoma is present in one eye with specified laterality. |
|
| H40.1132 | Bilateral primary open-angle glaucoma, moderate stage | Use when both eyes have moderate stage glaucoma. |
|
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: How do you code moderate stage open-angle glaucoma?
Essential facts and insights about Open-Angle Glaucoma, Moderate Stage
Primary ICD-10-CM Codes for open angle glaucoma moderate stage
Decision Criteria
clinical Criteria
- Presence of optic nerve cupping and visual field defects
Applicable To
- Moderate stage glaucoma in one eye
Excludes
- Bilateral glaucoma
Clinical Validation Requirements
- Optic nerve abnormalities
- Visual field defects in one hemifield outside 5° of fixation
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented to avoid unspecified codes.
H40.1132 - Bilateral primary open-angle glaucoma, moderate stage
Use when both eyes have moderate stage glaucoma.
Applicable To
- Moderate stage glaucoma in both eyes
Excludes
- Unilateral glaucoma
Clinical Validation Requirements
- Matching staging in both eyes
- Visual field defects in both eyes
Coding Notes
Ensure both eyes are documented as having the same stage.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Open-Angle Glaucoma, Moderate Stage to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H40.11X2.
Impact
Clinical: Inaccurate treatment planning, Regulatory: Non-compliance with coding guidelines, Financial: Potential claim denials
Mitigation Strategy
Always specify right, left, or bilateral in documentation
Impact
Reimbursement: Potential denial of claims, Compliance: Non-compliance with coding standards, Data Quality: Inaccurate clinical data
Mitigation Strategy
Cross-check documentation for specific stage and laterality.
Impact
Use of unspecified codes when specific stage is documented
Mitigation Strategy
Regular audits of documentation for completeness
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 Open-Angle Glaucoma, Moderate Stage, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Open-Angle Glaucoma, Moderate Stage
Use these documentation templates to ensure complete and accurate documentation for Open-Angle Glaucoma, Moderate Stage. These templates include all required elements for proper coding and billing.
Bilateral moderate stage glaucoma
Specialty: OphthalmologyRequired Elements
- IOP measurements
- Optic nerve assessment
- Visual field results
- Staging criteria
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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