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                 Your thoughts in my hands ....

ICD-10: Coding the New Glaucoma

Glaucoma is the leading cause of blindness in the United States, affecting more than 3 million people. It is the second leading cause of blindness in the world. Approximately half of all Glaucoma sufferers don’t know they have the disease, and their first medical appointment for vision loss may also be the first time they hear of it. Certain ethnicities are more affected than others, Glaucoma in African Americans is six to eight times as common as it is in Caucasians, and they are 15 times more likely than Caucasians to become visually impaired by the disease.  

It is likely that every ophthalmology practice will experience a growth in the number of glaucoma patients because of the aging of the American population and its anticipated growth in numbers. The overall population is expected to grow by 42% from 310 million in 2020 to 439 million in 2050, and the number of seniors is expected to track that statistic. Overall immigration numbers are expected to rise, as well, as seniors leave the workforce.

The direct and indirect cost of glaucoma to the US government will also rise as the number of diagnosed cases does. In 2006 the estimated cost for care and support of America’s 2,000,000 diagnosed sufferers was $2.9 billion. The number of diagnoses will also rise as older people enter the "senior" population.

Additionally, the financial burden to the country will increase as disease severity increases. The cost for medical management of stage 4 glaucoma (severe) was four times higher than for stage 1 (mild). Since many glaucoma patients are also now (or soon will be) Medicare or Medicaid patients, the cost of those programs for treating this disease are expected to rise exponentially over the next four decades.

The developers of the ICD-10 incorporated these population statistics when crafting the ICD-10 codes for glaucoma. They also noted that there was a great variability in costs and care across the country among glaucoma patients, even though the actual care received was comparable. Based on conclusions drawn from the combined data sets (expected growth in number of glaucoma patients and uneven level of expenditure per patient), it is expected that glaucoma will be a target for the use of value-based modifiers in coming years. It is anticipated that physicians will have to defend their costs of treatment and demonstrate improved outcomes to justify payments above “standard” levels for the disease. To prepare for this possibility, the new ICD-10 codes for glaucoma that reflect disease severity will allow for stratification of the physician’s glaucoma patient population, thereby building into the record the added expense of treating more severe cases. The new codes also incorporate digits for laterality.

The American Glaucoma Society work group developed the staging system. Enlisting the assistance of comprehensive ophthalmologists, optometrists and glaucoma specialists, they used real world tests to determine the accuracy of the severity levels. The ICD-9-CM Coordination and Maintenance Committee approved the system, which was officially incorporated into the ICD-10 in 2013.

General Notes for ICD-10 Coding:

The two indexes used for ICD-9 remain in ICD-10 – alphabetical and tabular. However, only the ICD-10 tabular list contains the full code digits for laterality and staging. Laterality can be seen at either the fifth or sixth digit; the seventh digit is always for staging. A code that does not have the full number of digits required will be invalid. 


The designation remains the same no matter where in the code (in other areas) it is required: 1 is for right; 2 is for left; 3 is bilateral, and “unspecific” is either 0 or 9. The lack of a sixth digit in the diagnostic code requires that "X" be used as a place marker. The first (2014) version of the ICD-10 did not have lateral codes for five glaucoma diagnoses, three of those were amended for the 2015-2016 version. The newer version of the ICD-10 does not incorporate laterality into two glaucoma code sections: other specified glaucoma (H40.89), and unspecified glaucoma (H.40.9).

ICD-10 Glaucoma Staging 2015-2016:

Staging is not required by all glaucoma coding but when it is, it is indicated under the category code. If the code includes an eye indicator, then "stage" each eye separately. If the diagnosis is the same for both eyes, use the bilateral code (3). If there is no indicator, use the staging code for the most severely affected eye.

There are five staging code digits, each of which specifies the advancing severity of the disease:

0 = unspecified:

1 = mild stage;

2 = moderate stage;

3 = severe stage, and

4 = indeterminate stage.   

Identifying the stage is based on the physician’s analysis of the printout of the visual field in the patient’s worst eye.

As an example, a full, valid code for “low tension glaucoma right eye, moderate stage” would read: “H40.1212”, with “H40.12” referring to the low tension glaucoma; "1" indicating right eye, and "2" indicating moderate stage.

Specific Coding Will Identify Trends, Improve Data:

The increase in the U.S. population will come from both births and immigration. By 2030, all of the generation born between 1945 and 1964 (the Boomers) will have moved out of the workforce, and many of those will have moved into “dependency” status. Immigration is expected to rise as foreign-born people arrive to fill the gap left by the Boomers. The influx of immigrants will mitigate the cost of caring for the seniors, but it will also bring new medical challenges and complications for health professionals to address.

Adoption of the ICD-10 brings the USA current with the rest of the World Health Organization countries in terms of data collection of globally relevant health information. As the population ages and morphs into the new “normal”, today’s physicians will be providing the data needed to develop systems and strategies to deal with those challenges. At the same time, detailed coding will develop each individual patient’s chart to reflect the totality of their condition, and to better guide diagnosis and treatment decisions. The new coding system around glaucoma will ensure that the nation’s eye health is fully documented, appropriately funded and focused on prevention.  

(c) PSornson 2005-2016