Find information on suspected glaucoma diagnosis, including clinical documentation, ICD-10 codes (H40.1, H40.9), medical coding guidelines, and healthcare resources. Learn about glaucoma suspect management, diagnostic testing, and relevant ophthalmology terminology for accurate medical record keeping and billing. Explore resources for eye care professionals and patients dealing with potential glaucoma.
Also known as
Glaucoma
Covers various types of glaucoma, including suspected cases.
Pain, unspecified
May be used if the suspected glaucoma presents with unspecified eye pain.
Visual disturbances
Relevant if suspected glaucoma causes vision changes like blurred vision.
Encounter for eye exam
Used for encounters specifically for glaucoma screening or evaluation.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is glaucoma confirmed?
Yes
Primary or secondary?
No
Is it suspected glaucoma?
When to use each related code
| Description |
|---|
| Suspected Glaucoma |
| Ocular Hypertension |
| Normal-Tension Glaucoma |
Coding glaucoma without specifying right, left, or bilateral eye can lead to claim denials and inaccurate data reporting. Use modifiers RT, LT, or OU.
Coding suspected glaucoma as confirmed without documented diagnostic testing can trigger audits and compliance issues. Code suspected cases appropriately.
Failing to code the stage of suspected glaucoma, if known, affects severity measurement and reimbursement. Include stage when documented.
Patient presents with concerns regarding potential glaucoma. Symptoms reported include intermittent blurred vision, occasional halos around lights, and mild ocular discomfort. Family history is positive for glaucoma. Intraocular pressure (IOP) measurements are borderline elevated in the right eye at 22 mmHg and within normal limits in the left eye at 18 mmHg. Optic nerve head evaluation reveals subtle cupping of the right optic disc with a cup-to-disc ratio of 0.6. The left optic disc appears normal with a cup-to-disc ratio of 0.4. Gonioscopy performed to assess the anterior chamber angle reveals open angles bilaterally. Visual field testing scheduled to assess for peripheral vision loss. Assessment includes suspected primary open-angle glaucoma, right eye. Differential diagnosis includes ocular hypertension, normal-tension glaucoma, and age-related visual changes. Plan includes close monitoring of IOP, repeat visual field testing in six months, patient education regarding glaucoma risk factors and treatment options, and consideration of topical glaucoma medication if IOP continues to rise or visual field defects are detected. ICD-10 code H40.101, suspected primary open-angle glaucoma, right eye, will be used for medical billing and coding purposes. Patient advised to follow up for repeat evaluation and management as scheduled.