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H31.099
ICD-10-CM
Retinal Scar

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

Chorioretinal Scar
Macular Scar

Diagnosis Snapshot

Key Facts
  • Definition : Permanent mark on retina from prior injury or disease.
  • Clinical Signs : Blurred vision, distorted vision, scotoma (blind spot), altered color perception.
  • Common Settings : Ophthalmology clinic, retina specialist, optometrist.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC H31.099 Coding
H35.0-

Retinal scars and other macular dystrophy

Covers various retinal scars, including macular dystrophies.

H36.0-

Pigmented retinal epiretinal membrane

Includes conditions causing retinal scarring, like epiretinal membranes.

H31.8-

Other retinal detachments

Retinal detachments can lead to retinal scarring as a sequela.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Retinal scar tissue
Chorioretinal scar
Epiretinal membrane

Documentation Best Practices

Documentation Checklist
  • Retinal scar location, size, and shape documented.
  • Etiology of retinal scar (e.g., trauma, infection) specified.
  • Impact on vision (e.g., visual field defect) noted.
  • Associated findings (e.g., retinal detachment) documented.
  • ICD-10 code H35.87 other retinal disorders documented.

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding retinal scar without specifying right, left, or bilateral eye leads to claim denials and inaccurate data.

  • Missing Etiology

    Failing to document the cause of the retinal scar (e.g., trauma, laser surgery) impacts severity and reimbursement.

  • Unclear Documentation

    Vague descriptions like "old scar" lack specificity for accurate ICD-10 coding (e.g., H35.1 vs H35.8).

Mitigation Tips

Best Practices
  • Document scar location, size, & etiology for accurate ICD-10 (H35.83) coding.
  • CDI: Query physician for details like cause & impact on vision for H35.83 specificity.
  • Ensure medical necessity for diagnostic tests & treatments related to retinal scar is documented.
  • Regular eye exams are key for early detection, monitoring, and compliance with preventative care.
  • Coding compliance: Link H35.83 to underlying conditions like chorioretinitis or trauma if applicable.

Clinical Decision Support

Checklist
  • Confirm scar location within retina using ICD-10 H35.x codes.
  • Document scar morphology (size, shape, pigment) for accurate coding.
  • Evaluate for underlying cause (e.g., chorioretinitis, laser) and document.
  • Assess visual acuity impact and document findings for patient safety.

Reimbursement and Quality Metrics

Impact Summary
  • Retinal Scar: Coding accuracy impacts reimbursement for ophthalmological procedures.
  • ICD-10 H35.6 affects DRG assignment and hospital case mix index reporting.
  • Proper documentation of etiology (e.g., trauma, laser) is crucial for accurate coding and billing.
  • Accurate retinal scar coding improves data quality for clinical outcomes analysis and research.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code H35.0 for retinal scar
  • Document scar location, size
  • Consider underlying cause code
  • Link scar to prior retinal event
  • Check laterality documentation

Documentation Templates

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.
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