ICD-10 Coding for Glaucoma Suspect(H40.011, H40.021)
Complete ICD-10-CM coding and documentation guide for Glaucoma Suspect. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Glaucoma Suspect
H40.0Primary Range
Glaucoma suspect
This range includes all codes related to glaucoma suspect, differentiated by risk factors, angle status, and laterality.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H40.011 | Open-angle glaucoma suspect, low risk, right eye | Use when the patient has open angles and ≤2 risk factors for glaucoma in the right eye. |
|
| H40.021 | Open-angle glaucoma suspect, high risk, right eye | Use when the patient has open angles and ≥3 risk factors for glaucoma in the right eye. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for glaucoma suspect
Essential facts and insights about Glaucoma Suspect
Primary ICD-10-CM Codes for glaucoma suspect
Decision Criteria
clinical Criteria
- Open angles confirmed by gonioscopy
documentation Criteria
- Document ≤2 risk factors
Applicable To
- Low-risk open-angle glaucoma suspect with ≤2 risk factors
Excludes
- High-risk open-angle glaucoma suspect
Clinical Validation Requirements
- Open angles on gonioscopy
- ≤2 risk factors documented
Code-Specific Risks
- Incorrectly coding as high risk without sufficient risk factors
Coding Notes
- Ensure risk factors are clearly documented to support low-risk classification.
H40.021 - Open-angle glaucoma suspect, high risk, right eye
Use when the patient has open angles and ≥3 risk factors for glaucoma in the right eye.
Applicable To
- High-risk open-angle glaucoma suspect with ≥3 risk factors
Excludes
- Low-risk open-angle glaucoma suspect
Clinical Validation Requirements
- Open angles on gonioscopy
- ≥3 risk factors documented
Coding Notes
Ensure risk factors are clearly documented to support high-risk classification.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Glaucoma Suspect to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H40.011.
Impact
Clinical: Inadequate clinical information for decision-making, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials due to insufficient documentation
Mitigation Strategy
Always include specific IOP measurements, Document the method of IOP measurement
Impact
Reimbursement: Claims may be denied due to non-billable codes, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate data representation in patient records
Mitigation Strategy
Specify risk level and laterality to use a billable code
Impact
Inadequate documentation of risk factors can lead to audit issues
Mitigation Strategy
Ensure all risk factors are explicitly documented in the patient record
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Glaucoma Suspect, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Glaucoma Suspect
Use these documentation templates to ensure complete and accurate documentation for Glaucoma Suspect. These templates include all required elements for proper coding and billing.
Ophthalmology Progress Note for Glaucoma Suspect
Specialty: OphthalmologyRequired Elements
- Chief complaint
- Subjective findings
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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