Understanding Retinal Scar diagnosis, documentation, and medical coding? Find information on retinal scar causes, symptoms like blurred vision or scotoma, and treatment options. Learn about accurate clinical documentation, ICD-10 codes for retinal scars (H35.83), differential diagnosis, and proper coding for healthcare professionals. Explore resources for retinal detachment scar, macular scar, chorioretinal scar, epiretinal membrane, and proliferative vitreoretinopathy related scarring.
Also known as
Retinal scars and other macular dystrophy
Covers various retinal scars, including macular dystrophies.
Pigmented retinal epiretinal membrane
Includes conditions causing retinal scarring, like epiretinal membranes.
Other retinal detachments
Retinal detachments can lead to retinal scarring as a sequela.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the retinal scar due to trauma?
Yes
Specify the nature of the trauma
No
Is it due to a previous retinal detachment?
When to use each related code
Description |
---|
Retinal scar tissue |
Chorioretinal scar |
Epiretinal membrane |
Coding retinal scar without specifying right, left, or bilateral eye leads to claim denials and inaccurate data.
Failing to document the cause of the retinal scar (e.g., trauma, laser surgery) impacts severity and reimbursement.
Vague descriptions like "old scar" lack specificity for accurate ICD-10 coding (e.g., H35.1 vs H35.8).
Patient presents with a retinal scar, clinically evident on funduscopic examination. The scar appears as a well-demarcated area of chorioretinal atrophy, possibly secondary to previous inflammation, trauma, or laser treatment. Patient reports [Symptom, e.g., blurred vision, visual field defect, no symptoms] in the affected eye. Visual acuity is [VA Measurement, e.g., 20/20, 20/40, hand motions]. The location of the retinal scar is documented as [Location, e.g., macular, peripheral, juxtafoveal] and measured at [Size Measurement, e.g., 500 microns] in diameter. Color and pigmentation are noted as [Description, e.g., hyperpigmented, hypopigmented]. Differential diagnoses considered include chorioretinitis scar, macular scar, post-traumatic retinal scar, and laser photocoagulation scar. The surrounding retina is assessed for any signs of edema, neovascularization, or retinal detachment. No active inflammation or other acute pathology is observed. Prognosis for visual recovery is dependent on the location and size of the scar. Patient education regarding the nature of retinal scarring, potential complications, and the importance of regular eye examinations is provided. Management includes monitoring for any changes in vision or the appearance of the scar. Follow-up ophthalmic examination scheduled in [Timeframe, e.g., 3 months, 6 months]. ICD-10 code H35.84 (Other retinal disorders) and CPT code 92250 (Ophthalmoscopy, extended, with retinal drawing and/or photography; with interpretation and report) are considered appropriate for this encounter. Medical necessity for further diagnostic testing or treatment will be determined based on the patient's clinical course.