Understanding visual changes? Find information on diagnosing and documenting visual disturbances, vision loss, blurred vision, visual field defects, and other ophthalmological symptoms. Learn about relevant ICD-10 codes, clinical documentation best practices, and healthcare resources for managing patients experiencing visual changes. This resource provides guidance for accurate medical coding and improved patient care related to vision problems and eye disorders.
Also known as
Disorders of visual pathways
Covers various visual impairments related to the optic nerve and pathways.
Disorders of optic nerve/visual field
Includes conditions affecting the optic nerve and resulting visual field defects.
Other disorders of eye and adnexa
Encompasses visual changes due to miscellaneous eye conditions not classified elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Sudden onset?
Yes
One eye affected?
No
Blurred vision?
When to use each related code
| Description |
|---|
| Visual Changes |
| Blurred Vision |
| Double Vision (Diplopia) |
Coding with unspecified codes like H53.9 (Visual disturbance, unspecified) when a more specific diagnosis is documented leads to inaccurate data and lost revenue.
Failing to distinguish between unilateral (one eye) and bilateral (both eyes) visual changes (e.g., using H53.1 for both) affects severity coding and reimbursement.
Coding only the visual change symptom (e.g., blurred vision) without coding the underlying cause (e.g., diabetes) impacts risk adjustment and quality reporting.
Patient presents with visual changes. Onset of symptoms reported as (date of onset). Character of visual disturbance includes (e.g., blurred vision, double vision, diplopia, floaters, flashes, visual field loss, hemianopsia, scotoma, photopsia, metamorphopsia, tunnel vision, halos around lights, night blindness, decreased visual acuity, color blindness, or other descriptive terms). Location of visual change is (e.g., unilateral right eye, unilateral left eye, bilateral, peripheral, central). Severity of symptoms described as (e.g., mild, moderate, severe, disabling). Duration of symptoms is (e.g., intermittent, constant, progressive, resolving). Associated symptoms include (e.g., headache, eye pain, eye redness, discharge, nausea, vomiting, dizziness, light sensitivity, photophobia, dry eyes, foreign body sensation, or none). Patient medical history includes (list relevant diagnoses such as diabetes, hypertension, glaucoma, macular degeneration, cataracts, retinal detachment, multiple sclerosis, stroke, trauma, or other relevant conditions). Medications include (list all current medications). Allergies include (list all allergies). Ocular examination reveals (detailed findings including visual acuity with and without correction, pupillary response, extraocular movements, anterior segment examination, fundoscopic examination findings, intraocular pressure, and any other relevant clinical findings). Differential diagnosis includes (list potential diagnoses such as refractive error, dry eye syndrome, corneal abrasion, uveitis, optic neuritis, retinal vascular occlusion, migraine aura, transient ischemic attack, or other relevant diagnoses). Assessment includes (working diagnosis based on examination and history). Plan includes (e.g., further diagnostic testing such as visual field testing, optical coherence tomography OCT, fluorescein angiography, or other relevant tests; referral to ophthalmology or other specialist; medication prescriptions; patient education regarding eye health, follow-up appointments, and treatment recommendations). Patient was counseled on (specific topics discussed including potential complications, treatment options, prognosis, and importance of adherence to treatment plan).