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February 23, 2004

Coding for Cataracts
Vol. 16 No. 4 p. 38

A cataract is a clouding or opaque area in the normally clear lens of the eye. Also called lens opacity, a cataract blocks the passage of light from the lens to the retina and may affect distance vision or cause problems with glare. It may progress to decreased visual acuity even in the daylight. Typically, there is no pain, abnormal tearing, redness, itching, irritation, aching, or discharge associated with cataracts. Patients have similar changes in both eyes, although one eye may be worse than the other.

Types of Cataracts
The most common cause of cataracts is age-related changes to the lens. Eyes are expected to have some degree of clouding due to age, which usually affects patients after the age of 60. As the lens changes with age, it breaks down, causing fibers of the lens to clump together, clouding small areas of the lens. It then continues to grow, covering more of the lens and becoming denser. Cataracts can be classified as the following:
• Immature — lens has some remaining clear areas
• Mature — lens is completely opaque
• Hypermature — lens has a liquefied surface that leaks through the capsule and may cause inflammation of other structures in the eye

The above classification does not affect the ICD-9-CM code assignment of cataracts unless the cataract is diagnosed as a senile cataract (366.1x). (The fifth digit subclassification depends on the specific type of cataract diagnosed.) A senile cataract is one that occurs later in life. However, the physician must document the cataract as senile—even if the patient is older—before a code for senile cataract can be assigned. The same is true for juvenile cataract (366.0x), which is a cataract that is characterized by onset early in life. Traumatic cataract, which is a cataract due to external injury, is classified to subcategory 366.2. Cataracts may be due to other ocular disorders (366.3x) or other diseases such as diabetes. A diabetic cataract is assigned to codes 250.5x and 366.41. However, it is rare for the patient to have a true diabetic cataract. If a diabetic patient has a senile cataract, assign codes 366.10 and 250.0x. (AHA Coding Clinic for ICD-9-CM, 1991, third quarter, page 9.) Occasionally, a cataract may develop as a side effect to a drug. If that is the case, assign code 366.45 for the drug-induced cataract. Assign an additional E code to identify the drug that caused the cataract.

Second cataract (366.5x), also known as after-cataract, is a type of cataract that occurs months or even years after the original cataract surgery. It occurs when the back of the lens capsule (the part of the lens that is not removed during surgery) eventually becomes cloudy and blurs vision.

A congenital cataract (743.3x) is a type of cataract that is present at birth or shortly after birth. Some common causes of congenital cataracts include the mother contacting rubella during pregnancy, chemical imbalance, developmental problems, or inherited. Congenital cataracts should be treated before the infant is 3 months old.

Signs and Symptoms
Common signs and symptoms of cataracts in adult patients include the following:
• clouded, blurred, or dim vision;
• increased difficulty with vision at night;
• sensitivity to light and glare (lights seem too bright);
• glare from lamps or sun;
• halos around lights;
• frequent change in eye wear prescriptions; and
• fading of colors.

In a baby, symptoms may include the following:
• baby does not respond to faces or objects; and
• baby scowls, squints, shields his or her eyes more than expected when in sunlight.

Diagnosis
The physician may perform one or more of the following tests to confirm the diagnosis of cataract:
• Visual acuity test — to determine how well letters can be read from across the room
• Slit-lamp examination — to detect any small abnormalities
• Retinal examination — after dilating the pupils, to examine lens for cataracts and determine the density of the clouding

Treatment
The only effective way to treat cataracts is by surgical removal. Cataract removal is the most common surgery performed on Americans over the age of 65. However, surgery does not always need to be performed. It depends on the degree to which the cataract affects the patient’s daily activities. Cataract surgery involves two parts: 1) Removal of clouded lens, and 2) replacement with a clear, artificial lens implant. An ICD-9-CM code needs to be assigned for both parts. The common surgical procedures for cataract removal include the following:
• Phacoemulsification (13.41) — removes cataract while leaving most of the outer layer (lens capsule) in place. Ultrasound breaks up the lens into small pieces.
• Extracapsular cataract extraction (ECCE) — done for denser cataracts. The lens capsule is opened, the nucleus is removed in one piece, and the softer lens cortex is vacuumed, leaving the capsule shell in place. It does not break up the lens. The code assignment, which depends on the technique performed, ranges from 13.2 to 13.59.

The lens implant, also known as intraocular lens (IOL) and pseudophakos, is made of plastic, acrylic, or silicone. Assign code 13.7x for the IOL insertion. Code 13.71 is assigned when the implant is inserted at the same time (same surgical episode) as the cataract removal. Code 13.72 is assigned if the implant is inserted at a subsequent operative episode.

Normally, only one eye is operated on at a time to allow the eye to heal before operating on the other eye. Full restoration of vision is possible if the patient does not have other eye disorders.

An after-cataract is typically treated with yttrium-aluminum-garnet (YAG [type of laser used]) laser capsulotomy. Capsulotomy of after-cataract is assigned to code 13.64, whether or not the YAG laser is used. Capsulectomy of after-cataract is classified to code 13.65. Also code any synchronous insertion of IOL (13.71).

Coding and sequencing for cataracts are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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