HIT 251 CODING PRACTICUM (MEDICINE SECTION ENCOUNTERS) What are the CPT and ICD-

Question

HIT 251 CODING PRACTICUM (MEDICINE SECTION ENCOUNTERS)

What are the CPT and ICD-10-CM codes

Ophthalmology Visit

SUBJECTIVE: This 77-year-old female comes in today for a new patient eye exam. She has newly diagnosed diabetes mellitus and complaints of impaired vision.

OBJECTIVE: BP 220/114, checked twice. Pulse rate 72 beats per minute. Snellen test without glasses showed visual acuity 20/40 left and right. Pupils were equal, round, reactive to light and accommodation. Cranial nerves intact. Mature cataracts noted bilaterally. Evaluation of the disks of her eyes was hampered by constriction of the pupils; however, some mild arteriolar narrowing could be detected. Funduscopy was inadequate because of the brisk papillary constriction.

ASSESSMENT 1. Impaired visual acuity secondary to cataracts and possibly effects from diabetes mellitus. 2. Hypertension. PLAN: She was advised to seek medical attention for the hypertension. Following a medical workup, we will evaluate the cataracts further and possibly consider surgery.

Explanation / Answer

1) The ICD code for impaired visual acuity secondary to cataract possibly due to diabetes is E 11.36

For Hypertension the CPT code is 99211 and ICD 10 code is 401.9

CPT code 66984 describes surgery for cataract

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