Experiencing decreased vision, visual impairment, or vision loss? This resource provides information on diagnosing and documenting decreased vision for healthcare professionals, including clinical definitions, ICD-10 codes related to low vision, and best practices for accurate medical coding. Learn about the causes of visual impairment, diagnostic criteria, and treatment options. Improve your clinical documentation and ensure proper coding for decreased vision.
Also known as
Blindness and low vision
Covers various types of vision impairment and blindness.
Visual disturbances
Includes disorders affecting visual function, not classified elsewhere.
Persons encountering health services
May be used for follow-up care related to decreased vision.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the decreased vision due to refractive error?
Yes, corrected by refractive lenses
No code for decreased vision. Code the refractive error (e.g., H52.0, H52.1).
Yes, uncorrected refractive error
Code the refractive error (e.g., H52.0, H52.1) and H54.7 (Unspecified visual disturbance).
No
Is the decreased vision sudden onset?
When to use each related code
| Description |
|---|
| Reduced visual acuity impacting daily activities. |
| Vision impairment due to refractive errors. |
| Age-related vision loss from macular degeneration. |
Coding lacks laterality (right, left, bilateral) impacting reimbursement and quality metrics. CDI should query for specificity.
Vision loss etiology (e.g., macular degeneration, glaucoma) often missed. Impacts risk adjustment and quality reporting.
Severity (mild, moderate, severe, profound) not documented. Impacts medical necessity for low vision aids and services.
Q: What are the most effective differential diagnostic approaches for sudden painless decreased vision in an adult patient?
A: Sudden painless decreased vision in an adult can indicate a variety of serious ophthalmological emergencies, necessitating a prompt and systematic differential diagnosis. The initial assessment should include a detailed history focusing on the onset, duration, and nature of the vision loss (e.g., blurred, hazy, shadowed), along with any associated symptoms like floaters, flashing lights, or pain. A comprehensive eye exam is crucial, encompassing visual acuity testing, pupillary assessment, slit-lamp examination, and funduscopy. Key differentials to consider include retinal artery occlusion, retinal vein occlusion, vitreous hemorrhage, retinal detachment, optic neuritis, and ischemic optic neuropathy. Further investigations such as optical coherence tomography (OCT), fluorescein angiography, and neuroimaging may be warranted depending on the initial findings. Explore how incorporating standardized diagnostic pathways can improve the speed and accuracy of diagnosing acute vision loss. Timely diagnosis is critical to preserving vision and minimizing long-term morbidity. Consider implementing a rapid triage system for patients presenting with sudden visual changes.
Q: How can clinicians effectively differentiate between age-related macular degeneration (AMD) and other causes of gradual central vision loss in older adults?
A: Distinguishing age-related macular degeneration (AMD) from other causes of progressive central vision loss in elderly patients requires a multi-faceted approach. While AMD is a common cause, other conditions like cataracts, diabetic retinopathy, and glaucoma can present with similar symptoms. A thorough clinical history, including family history of eye disease, medication use, and systemic conditions, is essential. Visual acuity assessment, Amsler grid testing for metamorphopsia, and dilated fundus examination are fundamental for evaluating the macula. Optical coherence tomography (OCT) is invaluable for visualizing retinal layers and identifying drusen, a hallmark of AMD. Fluorescein angiography may be useful for characterizing choroidal neovascularization in wet AMD. Differentiating between dry and wet AMD is critical for determining appropriate management strategies. Learn more about the latest advancements in AMD diagnosis and treatment to provide optimal patient care. Consider implementing regular screening for AMD in at-risk populations.
Patient presents with complaints of decreased vision, also described as visual impairment, low vision, or vision loss. Onset of symptoms is [onset timeframe - e.g., gradual over the past six months, sudden onset two days ago], impacting the patients ability to [activities of daily living affected - e.g., read, drive, recognize faces]. The patient reports [associated symptoms - e.g., blurry vision, double vision, halos around lights, eye pain, headache, floaters]. Medical history includes [relevant medical history - e.g., diabetes, hypertension, glaucoma, cataracts, macular degeneration, previous eye surgery or trauma]. Family history is positive/negative for [relevant family history - e.g., glaucoma, macular degeneration]. Visual acuity assessment revealed [specific visual acuity measurements for each eye - e.g., 20/40 OD, 20/60 OS]. Ocular examination findings include [detailed findings - e.g., normal fundus, presence of cataracts, optic nerve abnormalities]. Differential diagnosis includes [potential diagnoses - e.g., refractive error, cataracts, glaucoma, age-related macular degeneration, diabetic retinopathy]. Preliminary diagnosis is decreased vision, likely secondary to [suspected etiology - e.g., age-related macular degeneration]. Plan includes [diagnostic tests if needed - e.g., visual field testing, OCT, fluorescein angiography] and [treatment plan - e.g., referral to ophthalmology, prescription for corrective lenses, low vision rehabilitation services]. Patient education provided regarding [education topics - e.g., disease process, management strategies, follow-up care]. Return for follow-up in [timeframe - e.g., two weeks, one month] to reassess vision and discuss treatment progress. ICD-10 code considerations include [relevant ICD-10 codes - e.g., W91.XXA, H54.XX]. Medical billing codes may include [relevant CPT codes - e.g., 92004, 92014, 99203-99205]. Continued monitoring and management are indicated.