How to Use the ICD-10 Codes for Age-Related Macular Degeneration

CODING & REIMBURSEMENT SAVVY CODER

he ICD-10 codes for age-related BY FLORA LUM, MD, MICHAEL X. REPKA, MD, AND SUE VICCHRILLI, COT, OCS. macular degeneration (AMD) Tinvolve both laterality and staging. Correct staging enables more H35.31x1 for early dry AMD—a com- demarcated RPE and/or chorio- accurate characterization, which is im- bination of multiple small drusen (≤ 63 capillaris atrophy. Drusen and portant for understanding risk for visu- µm), few intermediate drusen (> 63 other pigmentary abnormalities al loss; it also helps to ensure accurate µm and ≤ 124 µm), or retinal pigment may surround the atrophic areas. documentation and efficient billing. epithelium (RPE) abnormalities. Severe visual acuity loss occurs H35.31x2 for intermediate dry less commonly and more slowly in Coding for Laterality in AMD AMD—extensive intermediate drusen patients with geographic atrophy When you use the codes for dry AMD (> 63 µm and ≤ 124 µm) or at least 1 than in patients with neovascular (H35.31xx) and wet AMD (H35.32xx), large drusen (≥ 125 µm). AMD. Nevertheless, geographic you must use the sixth character to H35.31x3 for advanced atrophic dry atrophy involving the foveal center indicate laterality as follows: AMD without subfoveal involvement— causes approximately 10% of all 1 for the right eye geographic atrophy (GA) not involving AMD-related visual loss of 20/200 2 for the left eye the center of the fovea. or worse.2 Patients with geographic 3 for bilateral H35.31x4 for advanced atrophic dry atrophy not necessarily involving Tip. If the same disease stage is AMD with subfoveal involvement—GA the central fovea may have relative- present in both eyes, use the bilateral involving the center of the fovea. ly good distance visual acuity yet designation (3) regardless of whether manifest a substantially decreased 1 or both eyes are being treated. Defining Geographic Atrophy ability to perform near visual The treatment code should indicate When is the retina considered atrophic? tasks such as reading.2 Doubling which eye is being treated. The Academy Preferred Practice Pattern1 of the visual angle in patients with defines GA as follows: geographic atrophy has been re- Coding for Staging in Dry AMD The phenotype of central geo- ported to occur in as many as 50% The codes for dry AMD—H35.31xx— graphic atrophy, the advanced of patients over a 2-year period.2 use the seventh character to indicate form of non-neovascular AMD, Choroidal neovascularization also staging as follows: will have 1 or more zones of well- may occur.

Table 1: Dry Age-Related Macular Degeneration (AMD)

Right Eye Left Eye Bilateral

Dry (nonexudative) AMD, early dry stage H35.3111 H35.3121 H35.3131

Dry (nonexudative) AMD, intermediate dry stage H35.3112 H35.3122 H35.3132

Dry (nonexudative) AMD, advanced atrophic without subfoveal involvement H35.3113 H35.3123 H35.3133

Dry (nonexudative) AMD, advanced atrophic with subfoveal involvement H35.3114 H35.3124 H35.3134

Key: Red numerals (6th position) indicate laterality; green numerals (7th position) indicate staging.

EYENET MAGAZINE • 61 Table 2: Wet Age-Related Macular Degeneration (AMD)

Right Eye Left Eye Bilateral

Wet (exudative) AMD, with active choroidal neovascularization H35.3211 H35.3221 H35.3231

Wet (exudative) AMD, with inactive choroidal neovascularization H35.3212 H35.3222 H35.3232

Wet (exudative) AMD, inactive scar H35.3213 H35.3223 H35.3233

Key: Red numerals (6th position) indicate laterality; green numerals (7th position) indicate staging.

Coding for Geographic Atrophy and eccentric fixation to read and (i.e., no IRF/SRF) that contributes to The Academy recommends that when perform other visual tasks. the patient’s visual impairment. coding, you indicate whether the GA Although not all eyes with H35.32x3 for inactive scar, which involves the center of the fovea: Code drusen or PED [pigment epithelial involves an AMD-related CNV lesion H35.31x4 if it does and H35.31x3 if it detachment] will develop atrophy, that has become a disciform scar, caus- doesn’t, with “x” indicating laterality the incidence of atrophy appears to ing visual impairment. The CNV lesion (see previous page). Improved cate- increase with age. Twelve to 20% of may or may not show disease activity gorization of GA will help in clinical patients with GA have severe vision (i.e., IRF/SRF), but it is deemed visually practice and also will lead to a better loss, and 10% of patients with AMD insignificant given the underlying disci- understanding of the natural history, and a visual acuity of 20/200 or less form scar. comorbidities, and visual prognosis have GA. Defining inactive CNV (H35.2x2) associated with the disease. and inactive scar (H35.2x3) in wet Why use a diagnosis code in the Coding for Staging in Wet AMD AMD. For the purpose of these ICD-10 absence of an approved therapy? The codes for wet AMD—H35.32xx— codes, the Academy defines inactive Accurate documentation and coding use the sixth character to indicate CNV as the absence of IRF or SRF. will help researchers and policymakers laterality and the seventh character to However, the same eye can have active track the visual impairment and visual indicate staging as follows: CNV after the diagnosis of inactive function deficits that are associated H35.32x1 for active choroidal CNV, and treatment can be considered with the condition. Furthermore, when neovascularization (CNV), which in- at the time of active CNV. Similarly, treatments do become available, you volves either (1) an AMD-related CNV an eye that has an inactive scar could will be ready to code for them. lesion that shows disease activity (i.e., have active CNV after the diagnosis of Prognosis. The risk of vision loss presence of intraretinal fluid [IRF] or an inactive scar, and treatment can be is higher with the involvement of the subretinal fluid [SRF]) contributing considered at the time of active CNV. macula; however, there can be difficul- to the patient’s visual impairment or ties with visual function in patients (2) an AMD-related CNV lesion that 1 American Academy of Ophthalmology Retina/ with GA without subfoveal involve- does not show disease activity (no Vitreous Panel. Preferred Practice Pattern Guide- ment. The Academy Basic and Clinical IRF or SRF) in the presence of regular lines: Age-Related Macular Degeneration. San Science Course3 notes the following re- anti–vascular endothelial growth factor Francisco, Calif.: American Academy of Ophthal- garding prognosis of patients with GA: (VEGF) injections but shows recur- mology; 2015. Available at: aao.org/ppp. GA often spares the fovea until late rence of the disease activity (i.e., IRF/ 2 Sunness JS et al. Ophthalmology. 1997;104(10): in the course of the disease. It may SRF) when anti-VEGF therapy is not 1677-1691. first present as 1 or more noncon- given at appropriate intervals. 3 American Academy of Ophthalmology BCSC tiguous patches of atrophy around H35.32x2 for inactive CNV, which Subcommittee. BCSC. Section 12: Retina and Vit- the fovea. These patches enlarge involves an AMD-related CNV lesion reous, 2016-2017. San Francisco, Calif: American and coalesce and may be associated that no longer shows disease activity Academy of Ophthalmology; 62-63. with a dense paracentral scoto- ma, thereby limiting tasks such as reading. Patients with GA may FOCUS ON PAYMENT POLICY AT AAO 2017 demonstrate good visual acuity Introduction to Physician Payment Policy (Sym12). A panel (VA) until late in the course of the will explain how new CPT codes are created and valued; how disease, when the fovea becomes existing codes are targeted for reevaluation; the impact of progressively atrophic, leading to new technology on the valuation of existing procedures; and the severe visual acuity decline from difference between CMS and commercial carrier coverage policies. central blindness and forcing the When: Sunday, Nov. 12, 11:15 a.m.-12:15 p.m. Where: Room 243. Access: Free. patient to use noncentral retina

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