New Medicare diagnosis codes apply to stages of glaucoma severity

The codes, slated to take effect Oct. 1, classify stages of glaucoma based on visual fields, risk and international classifications.

Cynthia Mattox

New Medicare glaucoma diagnosis codes that address glaucoma severity based on visual fields are scheduled to be implemented on Oct. 1, an expert said at the American Glaucoma Society meeting.

Many Medicare carriers already have policies in place allowing certain numbers of visual field or optic nerve imaging tests based on the severity of the glaucoma, and many private payers are currently using claims-based data to profile and rank physicians, according to Cynthia Mattox, MD, the chair of the AGS Patient Care Committee and a member of the AAO Health Policy Committee. Having physicians assign codes that reflect the actual clinical stage of disease will allow for more accuracy in claims-based payment or profiling methodologies that are already in place or may be designed in the future, she said.

“They’re not going to adversely impact our coverage policies now, so there’s no reason to be afraid of them,” Dr. Mattox said. “All of our original glaucoma diagnoses are still in there and will link to any coverage policies that are related to testing that we want to do or procedures that we want to do. … [They’re] also going to allow for some health policy research improvements, to be able to use claims-based codes so that we can understand a little bit more about the populations that everybody is taking care of.”

The new codes will be included in the current International Statistical Classification of Diseases and Related Health Problems Ninth Revision (ICD-9) as of Oct. 1, Dr. Mattox said. They will also be included in ICD-10, scheduled for publication in October 2013.

“These are going to be around for a while,” she said.

AGS work groups and experts from the American Academy of Ophthalmology drafted the new codes.

Stratified coding scheme

The new codes will address staging in the diagnosis of glaucoma and address suspected open-angle and primary angle- closure glaucoma, Dr. Mattox said.

“It’s a similar concept to codes for other diseases that we have in the eye, but we just didn’t have any severity coding or stratification of risk for glaucoma,” she said. “These are going to be add-on codes to all our usual codes. All of our codes will still be there.”

The staging codes include 365.71 for mild or early-stage glaucoma; 365.72 for moderate-stage glaucoma; 365.73 for severe, advanced or end-stage glaucoma; and 365.74 for undetermined glaucoma severity, Dr. Mattox said.

There will also be a code for unspecified glaucoma severity, Dr. Mattox said.

“Be sure to document staging in your records,” she said. “That will be helpful for coders or anybody who comes back to audit you.”

Stages of visual field loss

The AGS work groups surveyed clinicians before arriving at a system of staging for glaucoma severity. All stages require glaucomatous optic neuropathy, and then stratification is determined using visual field criteria, Dr. Mattox said.

“To use the codes, first select the underlying type of glaucoma, say, pseudoexfoliation glaucoma, 365.52. Then select the staging add-on code. For mild or early-stage glaucoma, you would have optic nerve abnormalities that are consistent with glaucoma, but no visual field loss on white-on-white perimetry,” she said. “Although there can be visual field loss on [short-wavelength automated perimetry] or [frequency-doubling technology] to be classified as mild.”

To code for moderate-stage glaucoma, optic nerve abnormalities must also be consistent with glaucoma, and glaucomatous visual field loss must be in one hemifield and not within 5° of fixation.

To code for severe, advanced or end-stage glaucoma, the clinician would identify optic nerve damage consistent with glaucoma, visual field abnormalities in both hemifields and/or visual loss within 5° of fixation.

“[The indeterminate code] would be used [when] you see a patient that you haven’t yet had time to do a visual field on, the patient just can’t perform a visual field test, or it’s so unreliable or uninterpretable that you really are unsure what level or stage they’re at,” Dr. Mattox said.

Codes based on risk

New revisions to codes for open-angle glaucoma suspects will be based on risk factors, Dr. Mattox said.

“We’re going to have a category for low risk, 365.01, which would be one to two risk factors, and a new code for high-risk open-angle glaucoma suspect, 365.05, where you have three or more risk factors,” she said.

Codes for primary angle-closure glaucoma were revised to conform with international classifications, Dr. Mattox said.

“The suspect code for anatomical narrow angle, 365.02, will still be there,” she said. “There’s a new code for primary angle closure without glaucoma damage, 365.06, meaning damage to the angle either with [peripheral anterior synechiae] or increased intraocular pressure but no optic nerve damage. The term ‘primary angle-closure glaucoma’ will be added to 365.23.”

Two words, “crisis” and “attack,” were also added to the coding terminology for acute angle-closure glaucoma, Dr. Mattox said. – by Matt Hasson

• Cynthia Mattox, MD, can be reached at New England Eye Center, 750 Washington St., Box 450, Boston, MA 02111; 617-636-8108; fax: 617-636-4866; email: cmattox@tuftsmedicalcenter.org.
• Disclosure: No companies or products are mentioned that would require financial disclosure.