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Documenting Glaucoma

Approximately three million people suffer from glaucoma in the United States. There is no cure at the present time, but there are treatment options. The options can include anything from medication (eye drops) to various types of surgery.

Glaucoma is actually a group of eye diseases that damage the optic nerve and can lead to blindness. The optic nerve is damaged by increased ocular pressure. The two main types of glaucoma are open angle (chronic) and closed angle (acute). The symptoms include:

  1. Intense pain (associated with the acute type of glaucoma)
  2. Redness in eye
  3. Misty vision
  4. Seeing rainbow-like halos
  5. Onset of visual disturbance, in which objects may appear to be distorted
  6. Eye irritability not related to vision
  7. Unusual response to light
  8. Headaches (including eye pain and blurred vision)
  9. Loss of peripheral vision (detected through a visual fields test)
  10. Loss of vision

From an ICD-10-CM perspective, laterality was added to primary open glaucoma subcategory in the updates for the 2017 fiscal year. The subcategory that expanded was H40.11-, and it now includes right, left, and bilateral. Glaucoma and related conditions can be found in the code range of H40-H42.

The clinical documentation requirements for glaucoma are identifying the type of glaucoma or related condition: open angle (H40.1-), closed angle (H40.22-), glaucoma suspect (H40.0-), or ocular hypertension (H40.05-). Glaucoma can affect both eyes or one eye. In fact, each eye can suffer from different types of glaucoma concurrently. 

The laterality (right, left, bilateral) documentation is important and supported by the 2017 ICD-10-CM Official Coding and Reporting Guidelines. The guidelines note that glaucoma that is “bilateral” can only be reported if the type and stage are the same. The last piece of documentation is the stage. 

There are five stages of glaucoma, including unspecified (0), mild (1), moderate (2), severe (3), and indeterminate (4). If the stage evolves during an admission, the coder would assign the highest stage. 

The indeterminate stage is based on clinical documentation indicating that the stage cannot be determined clinically. The indeterminate stage is not the same as not documented or unspecified.

You are at risk for glaucoma if you are over 40 years old; have a family history of glaucoma; are of African, Asian, or Hispanic heritage; run a high ocular pressure; have had an eye injury; or have the comorbidities of diabetes, migraines, high blood pressure, poor circulation, or other systemic chronic conditions. People who have a thin cornea center are also at risk of glaucoma.   

Detection can be determined during an initial screening by the age of 40. Based on medical history, family history, and screening results, an ophthalmologist can determine whether frequent screening should take place. If symptoms occur before age 40, then screening is recommended. Early detection is the key to maintaining eyesight.

Keep your eye on the ball and get your screening (if you haven’t done so already)!

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Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer

Laurie Johnson is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an AHIMA-approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and is a permanent panelist on Talk Ten Tuesdays

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