Find information on visual impairment diagnosis, including low vision, legal blindness, and best-corrected visual acuity. This resource covers clinical documentation requirements, ICD-10 codes (H54), medical coding guidelines, and healthcare best practices for visual impairment assessment and management. Learn about common eye conditions contributing to visual impairment, functional vision evaluation, and support services for patients with vision loss. Explore resources for healthcare professionals, including ophthalmologists, optometrists, and other clinicians involved in the care of visually impaired individuals.
Also known as
Blindness and low vision
Covers various types of visual impairment, including blindness.
Disorders of binocular vision
Includes conditions affecting both eyes, impacting visual function.
Diseases of the eye and adnexa
Broad category encompassing many eye conditions that can cause impairment.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the visual impairment best characterized by low vision?
Yes
Is it due to age-related macular degeneration?
No
Is the visual impairment best characterized by blindness?
When to use each related code
| Description |
|---|
| Vision loss impacting daily life. |
| Low vision, not correctable. |
| Blindness, severe vision loss. |
Inaccurate coding of right, left, or bilateral visual impairment (e.g., H54.1 vs. H54.2 vs. H54.3) impacting reimbursement and data analysis.
Undercoding or overcoding visual impairment severity (e.g., low vision vs. blindness, H54.0-H54.7) affecting quality metrics and resource allocation.
Missing documentation and coding of the underlying cause of visual impairment (e.g., diabetes, glaucoma) hindering appropriate care and research.
Patient presents with visual impairment, characterized by reduced visual acuity andor visual field loss. Presenting complaint includes difficulty with activities of daily living such as reading, driving, and facial recognition. Onset of visual impairment was gradualprogressiveacute (select one) and patient reports experiencing blurry vision, double vision, halos around lights, andor loss of peripheral vision (select all that apply). Medical history significant for (list comorbidities such as diabetes, hypertension, glaucoma, macular degeneration, cataracts, retinal detachment, optic neuritis, multiple sclerosis, or other relevant conditions). Family history includes (note any family history of eye diseases or genetic conditions). Ophthalmological examination reveals (document findings such as visual acuity measurements using Snellen chart or other methods, visual field testing results, intraocular pressure readings, funduscopic exam findings including optic nerve appearance, retinal abnormalities, and lens opacities). Diagnosis of visual impairment is confirmed based on clinical findings. Severity of visual impairment is classified as mild, moderate, severe, or profound (specify level). Treatment plan includes (detail interventions such as corrective lenses, low vision aids, medication management for underlying conditions, surgical intervention if applicable, referral to low vision specialist, occupational therapy for adaptive strategies, andor vision rehabilitation services). Patient education provided regarding (mention topics like disease management, medication adherence, safety precautions, adaptive techniques, and available resources). Follow-up scheduled for (specify date and time) to monitor visual function and assess treatment response. ICD-10 code (insert appropriate ICD-10 code such as H54. Specific code will depend on the specific type and etiology of the visual impairment). CPT codes for relevant procedures performed documented (list applicable CPT codes). Prognosis for visual function is (describe expected outcome based on current condition, treatment plan, and patient factors).