Billing and Coding for Amblyopia

Commonly known as “lazy eye”, amblyopia refers to a visual disorder that develops when there is a breakdown in how the brain and the eye work together and the brain cannot recognize the sight from one eye. This disorder occurs when the brain favors one eye over the other, leading to reduced vision in the weaker eye. In such specific diagnosed ocular, visual and visual perceptual conditions, vision therapy may be the only available and successful treatment option. Major medical or vision insurance plans may cover the treatments provided. However, it is important that ophthalmology practices accurately code the treatment procedures for all patients, whether using insurance or not. Accurate coding of amblyopia cases is crucial for delivering quality health care, ensuring accurate and timely medical documentation and medical billing. Ophthalmologists and visual therapy practices can rely on the services of a reliable ophthalmology medical billing company for accurate billing and coding and timely claim submission.

Before going on to the medical codes relevant for amblyopia, here is a brief look at the causes and symptoms of this eye condition.

Understanding the Causes and Symptoms of Amblyopia

Regarded as the most common cause of vision loss in kids, amblyopia starts in childhood. Reports suggests that up to 3 out of 100 children have it. Generally, this eye condition develops from birth up to age 7 years. It affects both eyes only rarely. However, early diagnosis and administration of treatment works well and can help prevent long-term problems with the child’s vision.

In many cases, ophthalmologists don’t know the exact factors that cause amblyopia. But in certain cases, refractive errors, strabismus and cataract can cause this condition. Symptoms of amblyopia can be hard to notice. Kids with amblyopia may have poor depth perception, meaning they have trouble telling how near or far something is. Other related symptoms include – an eye that wanders inward or outward, squinting or shutting an eye, head tilting and abnormal results of vision screening tests.

In most cases, parents don’t know their child has amblyopia until an ophthalmologist diagnoses it during an eye exam. Therefore, it is extremely important for all kids to get a vision screening at least once between ages 3 and 5. An eye exam will be performed to check for eye health, wandering eye and identify a difference in vision between the eyes or poor vision in both eyes. Treatment options depend on the cause of lazy eye and on how much the condition is affecting your child’s vision. A combination of treatment methods that includes corrective eyewear, eye drops, eye patches and surgery helps improve vision.

Now, for the ICD-10 diagnostic codes and CPT procedure codes respectively for amblyopia diagnosis and its treatments.

ICD-10 Codes for Amblyopia

Ophthalmology medical coding involves using the specific ICD-10 diagnosis codes for reporting amblyopia (lazy eye) on your medical claims. Here is a list of the ICD-10 codes for different types of amblyopia –

• H53 Visual disturbances
• H53.0 Amblyopia ex anopsia
  • H53.00 Unspecified amblyopia
  • H53.001 …… right eye
  • H53.002 …… left eye
  • H53.003 …… bilateral
  • H53.009 …… unspecified eye

• H53.01 Deprivation amblyopia
  • H53.011 …… right eye
  • H53.012 …… left eye
  • H53.013 …… bilateral
  • H53.019 …… unspecified eye

• H53.02 Refractive amblyopia
  • H53.021 …… right eye
  • H53.022 …… left eye
  • H53.023 …… bilateral
  • H53.029 …… unspecified eye

• H53.03 Strabismic amblyopia
  • H53.031 …… right eye
  • H53.032 …… left eye
  • H53.033 …… bilateral
  • H53.039 …… unspecified eye

• H53.04 Amblyopia suspect
  • H53.041 …… right eye
  • H53.042 …… left eye
  • H53.043 …… bilateral
  • H53.049 …… unspecified eye

There are specific subtypes of amblyopia (for example strabismic, deprivation amblyopia), and additional codes can be used to specify the subtype if known. However, in cases where the subtype is not specified, you can use the “unspecified amblyopia” code (H53.00).

CPT Codes for Amblyopia

Some casesof amblyopia can be successfully managed by prescription of therapeutic lenses and/or prisms. Most amblyopia diagnoses, however, may need optometric vision therapy. The treatment duration may vary depending upon the complexity or severity of the condition.

• Typically, the most commonly encountered amblyopia requires about 28 to 40 hours of office therapy.
• Amblyopia that is complicated by the following may require additional office therapy.
  • Related visual adaptations such as eccentric fixation, spatial distortion and anomalous correspondence
  • Associated visual anomalies such as strabismus, cataract and nystagmus
  • Associated conditions such as neurodevelopmental anomalies

The following CPT codes are applicable for an amblyopia diagnosis.

• 92065 – Orthoptic and/or pleoptic training, with continuing medical direction and evaluation (per session)
• 92070 – Orthoptic and/or pleoptic training, initial and subsequent, with medical direction and evaluation
• 92071 – Orthoptic and/or pleoptic training, with monitoring of ocular muscle imbalance (e.g., orthoptic training)
• 92072 – Orthoptic and/or pleoptic training, with vergence training (includes initial and subsequent sessions)

With medicine continuing its digital transformation, new digital codes have been introduced to report treatment procedures for amblyopia also.

• 0687T Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session
• 0704T-0706T: for remote treatment of amblyopia using an eye-tracking device and to cover device supply, technical support, interpretation and report.

Proper billing and coding for amblyopia are essential for healthcare providers to accurately document and bill for the diagnosis and treatment of this visual disorder. By using the appropriate diagnosis codes (ICD-10) and relevant procedure codes (CPT) for amblyopia management, healthcare providers can ensure proper reimbursement for the services rendered.

Coding for ophthalmology conditions can be challenging due to the complexity of different types of eye conditions, specific terminology, extensive code sets, coexistence of multiple conditions, and documentation challenges. Healthcare professionals should be diligent in selecting the most specific codes that accurately reflect the patient’s condition and the services provided. Utilizing modifiers when necessary and adhering to individual payer guidelines can help prevent claim denials and ensure compliance with billing regulations. Accurate and detailed documentation is key to support the medical necessity of services rendered, promoting transparency and accountability in the billing process. As medical coding and billing guidelines may change over time, providers should stay updated with the latest coding updates and regulations to maintain efficient billing practices. By following the appropriate billing and coding practices for amblyopia, healthcare providers can optimize their revenue cycle management and, most importantly, ensure that patients receive the necessary care and support for managing this visual impairment effectively.

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Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI. She is CPC certified by the American Academy of Professional Coders (AAPC).

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