The scenario describes a patient presenting with symptoms suggestive of a posterior segment pathology. The optometrist performs a comprehensive examination, including visual acuity, slit lamp biomicroscopy, and dilated fundus examination. The findings indicate significant changes in the macula, specifically drusen and pigmentary abnormalities, consistent with age-related macular degeneration (AMD). The question asks for the most appropriate ICD-10-CM code for this diagnosis. To arrive at the correct code, we must consider the specific findings and their implications for coding. The presence of drusen, particularly if they are large and numerous, along with pigmentary changes, points towards the intermediate or advanced stages of dry AMD. The ICD-10-CM coding system requires specificity regarding the laterality and type of macular degeneration. Considering the provided information, the most fitting code category for age-related macular degeneration is H35.3-. Within this category, we need to select the most precise code. The description of drusen and pigmentary changes, without mention of neovascularization or geographic atrophy, suggests a diagnosis that is not yet in the advanced neovascular or atrophic stages. Therefore, codes related to “other” forms of macular degeneration or unspecified macular degeneration are less appropriate than a code that specifically addresses the observed pathology. The most accurate ICD-10-CM code for age-related macular degeneration with drusen and pigmentary changes, assuming it is not specified as wet AMD or geographic atrophy, and considering the common presentation of intermediate dry AMD, is H35.3131, which denotes “Age-related macular degeneration, unspecified eye, intermediate.” If the documentation specified a particular eye, the code would be adjusted accordingly (e.g., H35.3111 for right eye, H35.3121 for left eye). However, given the general description, the unspecified eye code is the most appropriate choice reflecting the information provided. The explanation of the condition and its coding implications is crucial for a paraoptometric coder to accurately represent the patient’s diagnosis for billing and record-keeping purposes, aligning with the rigorous standards of Certified Paraoptometric Coder (CPOC) University.

The scenario involves a patient presenting with symptoms indicative of a posterior segment pathology. The initial examination reveals reduced visual acuity and the presence of floaters, which are common subjective complaints. The objective findings from the optical coherence tomography (OCT) are crucial for differentiating between various retinal conditions. The OCT scan specifically highlights lamellar macular holes and intraretinal cysts, particularly in the outer nuclear layer. This pattern is pathognomonic for a specific type of macular degeneration that affects the photoreceptor outer segments and the retinal pigment epithelium. While other conditions might cause visual disturbances, the detailed OCT findings of intraretinal fluid accumulation and disruption of the outer retinal layers, without significant drusen or geographic atrophy typically seen in dry AMD, point towards a wet form of macular degeneration or a related exudative process. Specifically, the description of lamellar changes and intraretinal cysts in the macula, coupled with the visual symptoms, strongly suggests a condition where there is leakage from choroidal neovascularization or altered fluid dynamics within the retina. Considering the options provided, the most accurate diagnosis based on the described OCT findings and symptoms is exudative macular degeneration. This condition is characterized by the growth of abnormal blood vessels beneath the retina, which can leak fluid and blood, leading to the observed cysts and lamellar disruptions. Other conditions like epiretinal membrane would typically show a cellophane-like layer on the surface of the retina, and diabetic macular edema, while causing intraretinal cysts, often presents with microaneurysms and hard exudates not explicitly mentioned here, and the pattern of lamellar disruption is more characteristic of exudative AMD. Central serous retinopathy could also cause subretinal fluid, but the intraretinal cysts and lamellar changes described are more specific to exudative AMD.

The scenario involves a patient with a confirmed diagnosis of primary open-angle glaucoma (POAG) who has undergone a trabeculectomy. Post-operatively, the patient presents with a shallow anterior chamber and elevated intraocular pressure (IOP). This clinical presentation strongly suggests a complication of the glaucoma surgery, specifically a choroidal effusion or a cyclodialysis cleft, both of which can lead to hypotony or a shallow anterior chamber. Given the elevated IOP, a cyclodialysis cleft is less likely as the primary cause of the elevated pressure, though it can contribute to other complications. A choroidal effusion, on the other hand, can occur post-surgically and, if significant, can lead to anterior segment crowding and elevated IOP due to angle closure or obstruction of aqueous outflow. In the context of coding for this patient’s follow-up visit at Certified Paraoptometric Coder (CPOC) University, the primary focus is on accurately reflecting the patient’s current condition and the services provided. The diagnosis of POAG remains relevant, but the post-operative complication requires specific coding. ICD-10-CM codes are used for diagnoses. For a post-operative complication of glaucoma surgery, specifically a shallow anterior chamber and elevated IOP following trabeculectomy, the appropriate ICD-10-CM code would fall under complications of surgical procedures. A relevant ICD-10-CM code for a complication of a procedure, specifically affecting the eye, would be from category H59, “Disorders of eye and adnexa following cataract surgery,” or more broadly, T85.310A for “Mechanical complication of intraocular lens, initial encounter,” if an intraocular lens was involved, or T85.390A for “Other mechanical complication of intraocular prosthetic devices, implants and grafts, initial encounter,” if the complication relates to the trabeculectomy filtering bleb or other implanted device. However, a more direct approach for post-surgical complications of glaucoma surgery, if not directly related to an implanted device like a glaucoma drainage device, would be to code the specific complication. A shallow anterior chamber post-glaucoma surgery is often coded under complications of procedures. Considering the options, a code reflecting a complication of glaucoma surgery, such as a shallow anterior chamber or hypotony maculopathy (though hypotony is not explicitly stated, a shallow chamber can lead to it), would be appropriate. If the elevated IOP is a direct consequence of the shallow anterior chamber, which is a complication of the trabeculectomy, then coding for the complication is paramount. Let’s assume the physician documented “Shallow anterior chamber following trabeculectomy.” The ICD-10-CM coding would involve identifying the specific complication. A code like H40.811 (Glaucoma secondary to other ocular disorders) might be considered if the shallow chamber was a secondary glaucoma, but this is a complication of the *treatment* for glaucoma, not a secondary glaucoma itself. A more precise approach for post-surgical complications is to use codes from Chapter 19 (Injury, poisoning and certain other external causes of morbidity) or Chapter 19 (External causes of morbidity) for complications of care. However, ICD-10-CM also has specific codes for complications of procedures. For post-surgical complications of the eye, codes within the H59 category are primarily for cataract surgery. For other ocular surgeries, the coder must look for specific codes or use general complication codes. A common approach for post-surgical complications not explicitly listed in a specific chapter is to use codes that describe the condition and link it to the procedure. If the shallow anterior chamber is the primary issue leading to elevated IOP, and it’s a direct result of the trabeculectomy, then a code indicating a complication of the trabeculectomy is needed. Let’s consider the scenario where the physician documents “Shallow anterior chamber, post-trabeculectomy, with elevated intraocular pressure.” The ICD-10-CM coding guidelines direct coders to report the complication. A code like T85.390A (“Other mechanical complication of intraocular prosthetic devices, implants and grafts, initial encounter”) might be used if a device was implanted during the trabeculectomy (e.g., a glaucoma drainage device). However, if it’s a standard trabeculectomy without a specific implant, the coding becomes more nuanced. A more accurate ICD-10-CM code for a complication of glaucoma surgery, specifically a shallow anterior chamber, would be found by looking for codes related to complications of ocular surgery. If the shallow anterior chamber is causing secondary glaucoma, then H40.811 would be considered. However, the question implies a direct complication of the surgery itself. A key consideration for Certified Paraoptometric Coders at CPOC University is understanding how to code for post-operative complications. The scenario describes a complication of a trabeculectomy. A shallow anterior chamber post-glaucoma surgery can lead to various issues, including elevated IOP. The ICD-10-CM code for a complication of a procedure is often specific. Let’s analyze the options based on common coding practices for post-surgical complications. The diagnosis of POAG is established. The trabeculectomy is the procedure. The complication is the shallow anterior chamber leading to elevated IOP. A code that directly reflects a complication of glaucoma surgery is needed. If the shallow anterior chamber is the primary issue, and it’s a complication of the trabeculectomy, then a code that signifies this is most appropriate. Consider the ICD-10-CM code T85.390A, “Other mechanical complication of intraocular prosthetic devices, implants and grafts, initial encounter.” While trabeculectomy itself isn’t always considered an “implant,” the concept of a surgical complication is captured. However, there might be more specific codes. A more precise ICD-10-CM code for a shallow anterior chamber post-glaucoma surgery, which is a complication of the procedure, would be H49.812, “Other cranial nerve palsies, unspecified nerve.” This is incorrect as it relates to nerve palsies. Let’s re-evaluate. The core issue is a complication of the trabeculectomy. A shallow anterior chamber is a known complication. If this shallow chamber leads to angle closure, it can cause elevated IOP. The correct approach is to identify the specific complication of the surgical procedure. A shallow anterior chamber post-glaucoma surgery is a complication. The ICD-10-CM code for a complication of ocular surgery, specifically a shallow anterior chamber, would be H49.812 if it were related to nerve issues, which it is not. A more appropriate ICD-10-CM code for a complication of ocular surgery, such as a shallow anterior chamber following a trabeculectomy, would be H40.811, “Glaucoma secondary to other ocular disorders.” This is still not ideal as it implies a secondary glaucoma, not a surgical complication. The most accurate ICD-10-CM code for a complication of glaucoma surgery, specifically a shallow anterior chamber, is H40.811. This code is used when glaucoma is secondary to other ocular disorders. In this context, the shallow anterior chamber is the “other ocular disorder” causing the elevated IOP, which is a manifestation of glaucoma. Therefore, coding the complication as a secondary glaucoma is the standard practice when the complication directly leads to increased intraocular pressure. The trabeculectomy is the procedure, and the shallow anterior chamber is the complication of that procedure. The elevated IOP is the consequence of the shallow anterior chamber. Thus, H40.811 accurately reflects the clinical picture of glaucoma secondary to a post-surgical complication.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the retina and potentially the optic nerve. The initial assessment involves visual acuity testing, which reveals a significant deficit in the right eye. Funduscopic examination, a crucial diagnostic step in optometry, is described as revealing “numerous small, punctate hemorrhages and cotton-wool spots scattered throughout the posterior pole of the right eye, sparing the macula.” Cotton-wool spots are indicative of localized retinal ischemia, a hallmark of conditions like diabetic retinopathy or hypertensive retinopathy. The presence of punctate hemorrhages further supports vascular compromise. Given the patient’s history of uncontrolled hypertension, the most appropriate ICD-10-CM code would reflect this underlying systemic condition as the cause of the ocular findings. The ICD-10-CM coding system requires specificity to accurately capture the patient’s condition and facilitate appropriate reimbursement and care management. When coding for ocular manifestations of systemic diseases, the coder must identify the underlying systemic condition and then link it to the specific ocular findings. In this case, the uncontrolled hypertension is the primary driver of the retinal changes. Therefore, the coding should begin with a code for hypertensive retinopathy. ICD-10-CM provides specific codes for hypertensive retinopathy, differentiating based on the severity of the changes observed. The description of “numerous small, punctate hemorrhages and cotton-wool spots” aligns with mild to moderate hypertensive retinopathy. Considering the options provided, the most accurate and comprehensive coding approach involves identifying the specific manifestation of hypertension on the retina. The presence of cotton-wool spots and hemorrhages directly points to hypertensive retinopathy. While other conditions might cause retinal hemorrhages, the context of uncontrolled hypertension strongly implicates it as the etiology. Therefore, a code that specifically denotes hypertensive retinopathy, reflecting the observed pathological changes, is necessary. The absence of macular involvement means that codes specifying macular edema or degeneration due to hypertension would be inappropriate. The question tests the ability to link systemic disease to its ocular sequelae and select the most precise ICD-10-CM code based on clinical findings, a core competency for a Certified Paraoptometric Coder at CPOC University.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the macula. The optometrist’s documentation notes “drusen and pigmentary changes in the macula,” which are hallmarks of age-related macular degeneration (AMD). The initial diagnostic code for this condition, based on the ICD-10-CM guidelines for AMD, would be H35.31-. The specific subcategory for “wet” AMD is H35.311 (for the right eye), H35.312 (for the left eye), or H35.313 (for bilateral). The subcategory for “dry” AMD is H35.321, H35.322, or H35.323. Given the description of “drusen and pigmentary changes,” this points towards the dry form of AMD. If the documentation specified exudative changes or neovascularization, wet AMD would be more appropriate. Without further detail to specify laterality, the most accurate general code for dry macular degeneration would be H35.329 (Unspecified eye). However, the question implies a need for a more specific code reflecting the documented findings. The presence of drusen and pigmentary changes is characteristic of early to intermediate dry AMD. ICD-10-CM guidelines direct coders to select the most specific code available. For dry AMD, the codes range from H35.321 to H35.323, depending on the affected eye. If the documentation is not specific about laterality, H35.329 is used. However, the question asks for the most appropriate code given the described findings, implying a need to select the correct subcategory. The presence of drusen and pigmentary changes, without mention of geographic atrophy or neovascularization, aligns with the definition of dry macular degeneration. Therefore, a code within the H35.32x range is indicated. Considering the options provided, the most precise code reflecting the described macular pathology, assuming bilateral involvement or unspecified laterality for the purpose of this question’s construction, would be H35.329, representing unspecified eye dry macular degeneration. However, if the question implies a need to select the most specific code for *dry* macular degeneration, and assuming the optometrist’s notes are comprehensive for the exam, the correct approach is to identify the code for dry macular degeneration. The ICD-10-CM structure for macular degeneration is H35.31x for wet and H35.32x for dry. The description “drusen and pigmentary changes” strongly suggests dry AMD. Thus, a code from the H35.32x series is correct. The most encompassing code for dry macular degeneration when laterality is not specified is H35.329.

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology. The optometrist performs a comprehensive examination, including a dilated fundus examination. The findings indicate a localized area of retinal thinning and pigmentary changes in the macula, consistent with early age-related macular degeneration (AMD). The paraoptometric coder’s responsibility is to select the most appropriate ICD-10-CM code that accurately reflects this diagnosis, considering the specificity required for proper reimbursement and statistical tracking. The ICD-10-CM coding system is structured hierarchically, with codes becoming more specific as more digits are added. For AMD, the primary category is H35.3, “Degeneration of macula and posterior pole.” Within this category, further specificity is needed to distinguish between different types and stages of macular degeneration. The patient’s symptoms and the optometrist’s findings point to a non-exudative (dry) form of AMD, characterized by drusen and geographic atrophy, rather than the exudative (wet) form which involves neovascularization. The documentation specifies changes in the macula, which is the central part of the retina responsible for sharp, central vision. Considering the options, H35.31 refers to “Age-related macular degeneration, unspecified eye.” H35.32 specifies “Age-related macular degeneration, right eye,” and H35.33 specifies “Age-related macular degeneration, left eye.” Since the explanation does not specify which eye is affected, the most appropriate code would be the unspecified eye code if no laterality is documented. However, if the documentation clearly indicates the affected eye, a more specific code would be used. Given the scenario implies a diagnosis has been made and documented, and assuming the documentation would specify laterality if known, the most precise code would reflect the affected eye. If the documentation only states “macular changes” without specifying laterality, H35.31 would be appropriate. However, for the purpose of demonstrating nuanced coding, let’s assume the documentation indicated the left eye. Therefore, the code H35.33, “Age-related macular degeneration, left eye,” is the most accurate and specific ICD-10-CM code for this patient’s condition, assuming the left eye was affected and documented as such. This level of specificity is crucial for accurate medical records, appropriate treatment planning, and successful insurance claims processing, aligning with the rigorous standards upheld at Certified Paraoptometric Coder (CPOC) University. The selection of the correct code demonstrates an understanding of the ICD-10-CM structure and the importance of clinical documentation in assigning precise diagnostic codes, a core competency for paraoptometric coders.

The scenario describes a patient presenting with symptoms suggestive of a posterior segment pathology. The paraoptometric coder must identify the most appropriate ICD-10-CM code for the documented findings. The patient’s history of hypertension is a significant comorbidity that may be relevant to the ocular condition. The fundus examination reveals drusen, which are characteristic of age-related macular degeneration (AMD). Specifically, the presence of soft drusen and pigmentary changes in the macula points towards the intermediate stage of dry AMD. While hypertension is noted, it is not directly stated as the *cause* of the macular changes, nor is there evidence of hypertensive retinopathy. Therefore, coding for hypertensive retinopathy would be inappropriate without a specific diagnosis linking the two. The presence of soft drusen and pigmentary changes without geographic atrophy or neovascularization aligns with the definition of intermediate dry AMD. The ICD-10-CM code H35.3131 specifically denotes “Intermediate dry age-related macular degeneration, right eye.” Given the documentation focuses on the right eye’s findings, this code is the most precise. Other options are less suitable: H35.35 (Drusen of macula, unspecified eye) is too general; H35.36 (Cystoid macular edema) is a different pathological process; and H35.10 (Retinal detachment, unspecified) is unrelated to the described findings. The explanation emphasizes the importance of precise coding based on specific clinical documentation, aligning with the rigorous standards expected at Certified Paraoptometric Coder (CPOC) University, where accuracy in translating clinical observations into billable codes is paramount. Understanding the nuances between different stages and types of macular degeneration, as well as the distinction between primary ocular conditions and those secondary to systemic diseases, is a core competency for paraoptometric coders.

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology, specifically affecting the macula. The optometrist performs a comprehensive examination, including optical coherence tomography (OCT) and fluorescein angiography (FA). The OCT reveals subretinal fluid and drusen, classic indicators of age-related macular degeneration (AMD). The FA confirms the presence of neovascularization, a hallmark of the wet form of AMD. When coding for this encounter at Certified Paraoptometric Coder (CPOC) University, the primary diagnosis must accurately reflect the identified pathology. The presence of drusen, coupled with subretinal fluid and neovascularization, points directly to wet AMD. Therefore, the appropriate ICD-10-CM code should capture this specific condition. The question requires identifying the most precise ICD-10-CM code for wet age-related macular degeneration with associated neovascularization. * **H35.3110** represents “Wet macular degeneration, right eye, unspecified.” * **H35.3190** represents “Wet macular degeneration, unspecified eye, unspecified.” * **H35.3130** represents “Wet macular degeneration, left eye, unspecified.” * **H35.3120** represents “Wet macular degeneration, left eye, unspecified.” The scenario does not specify which eye is affected, making a code that denotes an unspecified eye the most appropriate. Among the options, **H35.3190** is the most fitting as it captures “Wet macular degeneration” and specifies “unspecified eye” without further detail on laterality or the specific type of wet AMD (e.g., with geographic atrophy or subretinal neovascularization, which would require additional specificity if known and applicable). The other options specify a particular eye (right or left) which is not provided in the case.

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology, specifically impacting the macula. The optometrist performs a comprehensive examination, including visual acuity, slit lamp biomicroscopy, and optical coherence tomography (OCT). The OCT reveals drusen and pigment epithelial detachment (PED) in the macula, consistent with age-related macular degeneration (AMD). The patient’s visual acuity is recorded as 20/70 in the affected eye. To determine the appropriate ICD-10-CM code, we must first identify the primary diagnosis. The OCT findings of drusen and PED, coupled with reduced visual acuity, strongly indicate dry AMD with features of progression to wet AMD or a significant impact on visual function. The presence of PED, even in the context of dry AMD, often warrants consideration of codes that reflect the severity or specific findings. Considering the ICD-10-CM coding guidelines for AMD, we look for codes that specify the type and laterality. H35.31 (Age-related macular degeneration, dry) and H35.32 (Age-related macular degeneration, wet) are primary categories. However, the presence of PED suggests a more complex presentation. H35.33 (Age-related macular degeneration, unspecified) is too general. H35.36 (Age-related macular degeneration with geographic atrophy) and H35.37 (Age-related macular degeneration with neovascularization) are more specific. Given the description of PED, which can be associated with neovascularization or significant fluid accumulation, H35.37 is a strong candidate. The visual acuity of 20/70 in the affected eye indicates a significant visual impairment. ICD-10-CM guidelines often require coding for visual impairment when present. H54.12 (Moderate visual impairment, right eye) or H54.13 (Moderate visual impairment, left eye) would be used depending on the affected eye. Assuming the left eye is affected, H54.13 would be relevant. However, the question asks for the *most accurate* code for the *condition* as described, implying the primary diagnosis. The presence of PED, even if not explicitly stated as neovascularization, is a significant finding that often leads to or coexists with neovascular AMD. Therefore, a code reflecting this possibility is most appropriate. H35.329 (Age-related macular degeneration, wet, unspecified eye) or a more specific code if the eye was specified would be considered. If the PED is the primary concern and its nature (e.g., serous, fibrovascular) is not fully detailed, but it’s impacting vision, a code that captures the wet component or significant macular changes is best. Let’s re-evaluate the options based on common practice and the nuances of AMD coding. If the OCT confirms PED, it strongly suggests a neovascular component or a precursor to it, even if active leakage isn’t definitively seen on initial imaging. Therefore, coding for wet AMD is often the most prudent approach to capture the potential for progression and the severity of the findings. If the left eye is affected, and the findings are consistent with wet AMD, H35.322 (Age-related macular degeneration, wet, left eye) would be the most precise code for the macular pathology itself. The visual impairment would be a secondary code. The question asks for the coding of the *condition*, implying the primary diagnosis. Therefore, the correct approach is to identify the most specific ICD-10-CM code that accurately reflects the observed pathology. The presence of PED in the macula, along with reduced visual acuity, points towards a wet form of age-related macular degeneration. If the left eye is the affected eye, the code H35.322 accurately captures this diagnosis. This code is chosen because it specifies “wet” AMD and the affected eye, aligning with the clinical findings of PED which is a hallmark of wet AMD. Accurate coding is paramount at Certified Paraoptometric Coder (CPOC) University, as it directly impacts reimbursement, patient care tracking, and epidemiological studies. Misrepresenting the stage or type of AMD can lead to claim denials and affect the quality of data used for research and practice improvement initiatives championed by the university. Calculation: 1. Identify the primary diagnosis: Age-related macular degeneration with PED. 2. Determine the type of AMD: PED is indicative of wet AMD. 3. Identify the affected eye: Left eye. 4. Consult ICD-10-CM for the appropriate code: H35.32 (Age-related macular degeneration, wet) with the appropriate eye specifier. 5. Select the code for wet AMD in the left eye: H35.322. Final Answer: H35.322

The scenario involves a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the retina and potentially the optic nerve. The initial assessment includes visual acuity testing, which reveals a significant deficit in one eye. Further diagnostic imaging, such as Optical Coherence Tomography (OCT), is crucial for visualizing the detailed structure of the retina, identifying edema, exudates, or changes in the retinal layers. Fluorescein angiography would be employed to assess vascular integrity and detect leakage or non-perfusion, particularly relevant in conditions like diabetic retinopathy or macular edema. Given the potential for a progressive condition affecting central vision, accurate ICD-10-CM coding is paramount. The primary diagnosis would likely relate to the observed retinal pathology. For example, if the OCT shows significant macular edema, a code such as H36.01 (Diabetic retinopathy with macular edema) or H35.32 (Cystoid macular edema) might be considered, depending on the underlying etiology identified by the optometrist. If the visual field defect is significant and localized, it might suggest optic nerve involvement, leading to codes like H47.1 (Papilledema) or H47.5 (Other optic nerve disorders). The coding must reflect the most specific diagnosis supported by the clinical findings and diagnostic tests performed. The choice of CPT codes would then depend on the procedures performed. For instance, a comprehensive dilated fundus examination might be coded with 92250 (Fundus photography with or without optical coherence tomography), or if only OCT was performed, 92134 (Optical coherence tomography of posterior segment, unilateral or bilateral). The explanation focuses on the diagnostic process and the importance of linking clinical findings to appropriate diagnostic and procedural codes within the ICD-10-CM and CPT systems, emphasizing the paraoptometric coder’s role in accurately representing the patient’s condition and the services rendered at Certified Paraoptometric Coder (CPOC) University.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the retina and potentially the optic nerve. The initial coding for the comprehensive eye examination would fall under Evaluation and Management (E/M) services, typically coded using CPT codes that reflect the level of detail and complexity of the examination performed. Given the mention of dilated fundus examination and the subsequent findings of retinal hemorrhages and optic nerve pallor, the coder must select appropriate diagnostic codes from ICD-10-CM. Retinal hemorrhages are classified under H35.0, which encompasses various non-proliferative and unspecified retinal hemorrhages. Optic nerve pallor, often indicative of optic atrophy or damage, is coded under H47.4, specifically for optic nerve atrophy. The presence of both conditions requires accurate coding to reflect the full clinical picture presented to the payer. The coder’s responsibility is to translate these clinical findings into universally recognized alphanumeric codes for accurate reimbursement and medical record keeping, adhering to the specific guidelines of ICD-10-CM for specificity and sequencing. The correct approach involves identifying the primary and secondary diagnoses that best represent the patient’s ocular health status as documented by the optometrist.

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology, specifically affecting the macula. The optometrist performs a comprehensive examination, including visual acuity, slit-lamp biomicroscopy, and optical coherence tomography (OCT). The OCT reveals drusen and pigment epithelial detachment (PED) in the macula, consistent with age-related macular degeneration (AMD). The patient’s visual acuity is recorded as 20/70 in the affected eye. To determine the appropriate ICD-10-CM code, we must first identify the primary diagnosis. The OCT findings and symptoms point to Age-Related Macular Degeneration. Within ICD-10-CM, AMD is classified under H35.3-. The specific subcategory depends on whether it is dry or wet AMD, and if there are associated complications like geographic atrophy or subretinal neovascularization. Given the mention of PED, which can be associated with both dry and wet AMD, and the need to capture the severity, we look for codes that reflect the macular involvement. The visual acuity of 20/70 in the affected eye is a significant finding that needs to be coded. ICD-10-CM provides specific codes for visual impairment. H54.2- codes represent moderate visual impairment, with categories for bilateral or unilateral involvement. Since the OCT findings are described in “the affected eye,” and no bilateral findings are mentioned, we focus on unilateral impairment. H54.22, “Moderate visual impairment, left eye,” or H54.21, “Moderate visual impairment, right eye,” would be appropriate if the affected eye were specified. However, the question implies a focus on the diagnosis of AMD itself and its impact, rather than solely the visual impairment category without a specified eye. Considering the provided options, we need to select the code that best represents the diagnosed condition and its impact. The presence of drusen and PED in the macula, leading to reduced visual acuity, strongly suggests a form of macular degeneration. The most encompassing and accurate ICD-10-CM code for this scenario, without further specification of wet or dry AMD or geographic atrophy, would be a code that denotes macular degeneration with significant visual impairment. Let’s analyze the options in relation to the scenario: A code for “Age-related macular degeneration, unspecified eye, with moderate visual impairment” would accurately capture the core diagnosis and its functional consequence. Such a code would reflect the optometrist’s findings and the patient’s visual status. The explanation for the correct answer will focus on the diagnostic findings (drusen, PED) and the visual acuity (20/70) to justify the selection of a code that encompasses both. The presence of PED, a detachment of the retinal pigment epithelium, is a key indicator of potential progression or a more advanced stage of AMD, necessitating a code that reflects this complexity. The visual acuity of 20/70 falls within the range of moderate visual impairment, further supporting the need for a code that includes this functional deficit. The principle of coding for the most specific diagnosis supported by documentation is paramount in Certified Paraoptometric Coder (CPOC) University’s curriculum, emphasizing the importance of linking clinical findings to appropriate diagnostic codes.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the macula. The visual acuity of \(20/100\) in the right eye, coupled with metamorphopsia and a central scotoma, strongly suggests macular dysfunction. Given the patient’s age and the progressive nature of the symptoms, age-related macular degeneration (AMD) is a primary differential diagnosis. The question asks for the most appropriate ICD-10-CM code for this presentation, considering the provided clinical information. To arrive at the correct code, we must analyze the diagnostic indicators. The visual acuity deficit points towards a specific category within the ICD-10-CM system related to visual impairment. The description of metamorphopsia and a central scotoma are classic symptoms of macular disease. When coding for conditions affecting vision, it is crucial to consider both the underlying pathology and the degree of visual impairment. In ICD-10-CM, codes for visual impairment are often found in categories H54.0-H54.7. Specifically, H54.7 refers to “Unspecified visual impairment.” However, the clinical details provided allow for a more specific diagnosis. The symptoms of metamorphopsia and central scotoma, in the context of a reduced visual acuity of \(20/100\), are highly suggestive of macular degeneration. The ICD-10-CM code H35.35, “Macular degeneration of macula and central retina,” is the most appropriate code for a patient presenting with symptoms of metamorphopsia and a central scotoma, especially when accompanied by reduced visual acuity. This code specifically addresses the location and nature of the pathology. Further specificity might be added with laterality (e.g., H35.351 for right eye, H35.352 for left eye, H35.353 for bilateral) and type of macular degeneration (e.g., dry or wet), but based solely on the information provided, H35.35 accurately captures the core diagnostic findings. The visual acuity of \(20/100\) is consistent with moderate visual impairment, which is often associated with macular degeneration. Therefore, the coding decision hinges on identifying the most specific ICD-10-CM code that encompasses the described clinical presentation of macular pathology and its functional impact.

The scenario describes a patient presenting with symptoms indicative of a posterior uveitis, specifically affecting the macula. The initial diagnostic workup includes Optical Coherence Tomography (OCT) and fluorescein angiography. The OCT reveals subretinal fluid and intraretinal cysts, consistent with macular edema. The fluorescein angiography demonstrates punctate hyperfluorescence in the early phases and late leakage, suggesting inflammatory exudation and potential disruption of the outer blood-retinal barrier. Given the clinical presentation and diagnostic findings, the most appropriate ICD-10-CM code for the primary diagnosis would be H35.371, which specifically denotes cystoid macular edema, right eye. This code accurately reflects the observed pathology in the macula. While other conditions like posterior uveitis (H48.00) or unspecified retinal edema (H36.89) might be considered, they are less specific to the documented macular involvement. The presence of subretinal fluid and intraretinal cysts directly aligns with the definition of cystoid macular edema. Therefore, H35.371 is the most precise and clinically relevant diagnostic code for this presentation, ensuring accurate medical record documentation and appropriate billing for services rendered at Certified Paraoptometric Coder (CPOC) University.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the retina and potentially the optic nerve. The initial diagnostic steps involve evaluating visual acuity, intraocular pressure, and performing a dilated fundus examination. The mention of “floaters” and a “shadow obscuring the peripheral vision” strongly suggests a condition involving the vitreous humor or retinal detachment. Optical Coherence Tomography (OCT) is a crucial imaging modality for visualizing the retinal layers and detecting subtle changes, such as edema, exudates, or structural disruptions, which are common in conditions like diabetic retinopathy or macular degeneration. Fluorescein angiography is indicated when vascular abnormalities, leakage, or ischemia are suspected, particularly in diabetic retinopathy or retinal vascular occlusions. Given the patient’s history of diabetes, diabetic retinopathy is a primary consideration. The coding for such a presentation would involve identifying the specific diagnosis (e.g., diabetic retinopathy with macular edema) and the procedures performed. For instance, if the OCT revealed macular edema, the ICD-10-CM code for diabetic retinopathy with macular edema would be applied, and the OCT procedure itself would be coded using CPT. The explanation focuses on the diagnostic process and the rationale for selecting specific tests and potential diagnostic codes, aligning with the paraoptometric coder’s role in accurately translating clinical findings into billable codes. The correct approach involves understanding the interplay between symptoms, diagnostic tests, and their corresponding medical terminology and coding systems, emphasizing the importance of accurate documentation for reimbursement.

The scenario describes a patient presenting with symptoms indicative of a specific ocular condition. The paraoptometric coder’s task is to accurately translate the optometrist’s findings and the patient’s diagnosis into universally recognized medical codes for billing and record-keeping. The key is to identify the most precise ICD-10-CM code that encapsulates the described pathology and its impact. The patient’s history of diabetes mellitus is a crucial comorbidity that influences the coding. Diabetic retinopathy, specifically proliferative retinopathy with macular edema, is the primary diagnosis. The presence of vitreous hemorrhage further refines the specificity required for accurate coding. The ICD-10-CM coding system is hierarchical, meaning that more specific codes are preferred over general ones. Diabetic retinopathy is classified under E08-E13 (Diabetes mellitus) and H36 (Other disorders of retina in diseases classified elsewhere). Specifically, diabetic retinopathy is found under H36.0. Further subclassification is necessary to denote the type and severity. Proliferative diabetic retinopathy is coded as H36.01. The presence of macular edema necessitates an additional code to specify this complication. Macular edema associated with diabetic retinopathy is coded under H36.011 (Proliferative diabetic retinopathy with macular edema, unspecified eye) or more specifically if the eye is specified. Given the description of “both eyes” being affected, the most appropriate code for proliferative diabetic retinopathy with macular edema in both eyes is H36.013. However, the question implies a specific presentation that needs to be captured. The provided scenario details “bilateral proliferative diabetic retinopathy with significant macular edema.” This requires a code that captures both the proliferative nature and the macular edema, and specifies bilaterality. Reviewing the ICD-10-CM structure, diabetic retinopathy is linked to the type of diabetes. Assuming Type 2 diabetes (E11), diabetic retinopathy would be coded under E11.3-. The subcategory E11.35 specifies “Type 2 diabetes mellitus with proliferative diabetic retinopathy.” Further refinement is needed for macular edema. E11.351 specifies “with macular edema.” For bilateral involvement, the code becomes E11.3513. This code accurately reflects the patient’s condition as described: Type 2 diabetes, proliferative retinopathy, macular edema, and bilateral involvement. Therefore, E11.3513 is the most precise and appropriate ICD-10-CM code for this clinical presentation, aligning with the principles of specificity and accurate documentation essential for Certified Paraoptometric Coders at CPOC University.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the macula. The optometrist performs a comprehensive examination, including visual acuity, slit-lamp biomicroscopy, and optical coherence tomography (OCT). The OCT reveals subretinal fluid and drusen, classic findings associated with age-related macular degeneration (AMD). The patient’s visual acuity is significantly reduced in the affected eye. When coding this encounter for Certified Paraoptometric Coder (CPOC) University standards, the primary diagnosis must accurately reflect the identified pathology. The presence of subretinal fluid and drusen, coupled with reduced visual acuity in the macula, points towards wet AMD, a more advanced and potentially rapidly progressing form of AMD. Therefore, the most appropriate ICD-10-CM code would be one that specifies the presence of exudative or neovascular changes in the macula. Considering the diagnostic findings, the correct approach involves identifying the ICD-10-CM code that best captures the severity and specific manifestation of the macular pathology. Codes related to dry AMD, without exudation, would be less precise. Similarly, codes for general visual impairment or other retinal conditions not supported by the OCT findings would be incorrect. The coding must be specific enough to reflect the clinical evidence presented in the case. The specific code for wet AMD, often characterized by neovascularization and exudation, is crucial. In ICD-10-CM, this is typically represented by codes within the H35.3 category, further specified by subcategories that denote the presence of exudation or neovascularization. For instance, H35.32- (Exudative macular degeneration) or similar codes that explicitly mention neovascularization would be the most accurate. Without specific sub-codes for laterality or further detail, the general category for exudative macular degeneration is the most fitting.

The scenario involves a patient presenting with symptoms indicative of a posterior segment pathology. The initial diagnostic coding for the presenting symptom of blurred vision is H53.10 (Unspecified visual disturbances). However, upon further examination, Optical Coherence Tomography (OCT) reveals significant drusen deposits and geographic atrophy in the macula. These findings are pathognomonic for age-related macular degeneration (AMD). The ICD-10-CM coding guidelines mandate that when a definitive diagnosis is established, the specific diagnosis code should be used in place of the symptom code. Geographic atrophy is a more advanced form of dry AMD. Therefore, the most accurate ICD-10-CM code reflecting the OCT findings is H31.313 (Geographic atrophy, unspecified eye). This code specifically addresses the observed atrophy in the macula, which is the underlying pathology causing the visual disturbances. The other options are less precise or represent different conditions. H35.31 (Macular degeneration, unspecified) is too general. H31.30 (Degeneration of macula and posterior pole) is also less specific than geographic atrophy. H40.9 (Glaucoma, unspecified) is incorrect as the findings do not suggest glaucoma. The paraoptometric coder’s role is to translate clinical findings into accurate diagnostic codes, ensuring proper reimbursement and medical record documentation, which is a core competency at Certified Paraoptometric Coder (CPOC) University.

The scenario describes a patient presenting with symptoms indicative of a posterior uveitis. The key elements are the sudden onset of floaters, blurred vision, and photophobia, coupled with the ophthalmologist’s finding of vitreous cells and a posterior vitreous detachment (PVD). In the context of ICD-10-CM coding, the primary diagnosis for the observed inflammation within the posterior segment of the eye is H44.03, “Vitreous humor inflammation.” This code specifically captures the presence of inflammatory cells or exudates within the vitreous, aligning with the clinical findings. While a PVD is present (H43.31), it is often a consequence or associated finding of uveitis rather than the primary condition requiring coding for the inflammatory process itself. The symptoms of blurred vision and photophobia are manifestations of the underlying inflammation and would not be coded separately as primary diagnoses in this context, as they are integral to the uveitis. Therefore, the most accurate and specific ICD-10-CM code to represent the ophthalmologist’s findings and the patient’s condition, as it pertains to the inflammation within the vitreous humor, is H44.03. This aligns with the principle of coding the most specific diagnosis that explains the patient’s presentation and the physician’s findings.

The scenario describes a patient presenting with symptoms indicative of a specific ocular condition. The paraoptometric coder must accurately identify the most appropriate ICD-10-CM code based on the documented findings and the established coding guidelines for ophthalmology. The patient’s history of hypertension and diabetes mellitus are crucial comorbidities that may influence coding, particularly if they are stated as contributing to the ocular condition. The description of “gradual, painless, bilateral vision loss, more pronounced in the central visual field, with observed drusen and geographic atrophy in both maculae” strongly points towards age-related macular degeneration (AMD). Specifically, the presence of geographic atrophy signifies the advanced, “dry” form of AMD. The ICD-10-CM coding system requires specificity. For dry AMD with geographic atrophy, the appropriate code is H35.313. The “3” in the code indicates “both eyes.” While the patient has comorbidities, these are not directly coded as the primary diagnosis unless they are the focus of the encounter or are explicitly linked as causative factors in a way that alters the primary diagnosis coding. The question tests the ability to translate clinical presentation into the correct diagnostic code, emphasizing the importance of anatomical location (macula), laterality (both eyes), and the specific pathological process (geographic atrophy) as dictated by ICD-10-CM structure. Understanding the nuances of coding for degenerative conditions of the eye, and how to differentiate between various stages and types of macular degeneration, is fundamental for accurate reimbursement and data analysis within optometric practice, a core competency at Certified Paraoptometric Coder (CPOC) University.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the macula. The optometrist’s documentation notes “drusen and pigmentary changes in the macula,” which are hallmark signs of early age-related macular degeneration (AMD). The patient’s reported visual disturbances, such as blurred central vision and difficulty reading fine print, further support this diagnosis. When coding for such a presentation at Certified Paraoptometric Coder (CPOC) University, the primary objective is to accurately reflect the diagnosed condition and its severity. The ICD-10-CM coding system requires specific codes for AMD. For early stages characterized by drusen and pigmentary changes without significant visual impairment or neovascularization, the appropriate code falls within the H35.3 category. Specifically, H35.31 refers to “Age-related macular degeneration.” Further specificity is provided by subcategories. H35.311 denotes “Age-related macular degeneration, right eye,” H35.312 for the left eye, and H35.313 for both eyes. Given the documentation mentions “macula” generally without specifying laterality, and assuming the changes are bilateral as is common in early AMD, H35.313 would be the most appropriate initial code. However, if the documentation were more precise, indicating changes in only one eye, the corresponding laterality code would be used. The question also implicitly touches upon the importance of accurate documentation for coding. The optometrist’s detailed notes about drusen and pigmentary changes are crucial for selecting the correct ICD-10-CM code. Without this specificity, a coder might default to a less specific code, potentially impacting reimbursement and patient care tracking. At CPOC University, emphasis is placed on understanding how clinical findings translate into precise diagnostic codes, ensuring compliance with payer guidelines and reflecting the true nature of the patient’s condition. The selection of H35.313 directly addresses the described macular pathology, aligning with the principles of accurate and comprehensive coding taught in the program.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the retina and potentially the optic nerve. The initial assessment involves visual acuity testing, which is a fundamental component of any comprehensive eye examination. The mention of “blurry vision, floaters, and flashes of light” strongly suggests a condition like a posterior vitreous detachment (PVD) or a retinal tear. Given the patient’s age and the progressive nature of the symptoms, a retinal detachment is a significant concern. The paraoptometric coder’s role is to accurately translate the clinical findings and the optometrist’s diagnosis into standardized codes for billing and record-keeping. In this context, the paraoptometric coder must identify the most appropriate ICD-10-CM code that reflects the diagnosed condition. Let’s analyze the potential diagnoses and their corresponding ICD-10-CM codes: * **Posterior Vitreous Detachment (PVD):** This is a common age-related condition where the vitreous gel separates from the retina. Symptoms often include floaters and flashes. The ICD-10-CM code for PVD is H43.81. * **Retinal Tear:** This occurs when the retina tears, often due to PVD. It can lead to retinal detachment if left untreated. The ICD-10-CM code for retinal tear is H33.20 (unspecified retinal detachment) or more specific codes if the location is known. However, if the tear is confirmed without detachment, H33.20 might be used as a precursor or if the detachment is not yet specified. * **Retinal Detachment:** This is a serious condition where the retina separates from the underlying tissue. It requires prompt treatment. The ICD-10-CM code for unspecified retinal detachment is H33.20. If the detachment is specified as rhegmatogenous (due to a tear), H33.00 would be used. * **Vitreous Hemorrhage:** This is bleeding into the vitreous humor, which can cause floaters and vision loss. The ICD-10-CM code is H43.10. Considering the patient’s symptoms of blurry vision, floaters, and flashes, and the optometrist’s suspicion of a retinal issue that could lead to detachment, the most encompassing and appropriate initial diagnostic code, reflecting the potential for a serious posterior segment pathology that requires further investigation and management, would be one that signifies a retinal detachment or a precursor to it. If the optometrist’s examination confirms a retinal tear that has not yet progressed to a full detachment, or if the symptoms are strongly suggestive of an impending detachment that needs immediate attention, the coder must select the code that best represents this clinical suspicion and the urgency. The ICD-10-CM code H33.20, “Retinal detachment, unspecified,” is a strong candidate because it covers the broad category of detachment, which is the primary concern given the symptoms and the potential progression. While H43.81 (PVD) is a possibility, the flashes of light and blurry vision, in conjunction with floaters, elevate the concern beyond a simple PVD to a potential retinal tear or detachment. H33.00 would be used if a rhegmatogenous detachment is confirmed. Given the scenario, the optometrist is investigating a potentially serious condition, and H33.20 serves as a valid code for an unspecified retinal detachment or a strong suspicion thereof, guiding further management and coding. The correct approach is to select the ICD-10-CM code that most accurately reflects the optometrist’s documented findings and the patient’s condition, prioritizing codes that indicate the severity and potential progression of the ocular pathology. In this case, the symptoms point towards a significant posterior segment issue, and H33.20 is the most appropriate code to represent an unspecified retinal detachment, which aligns with the optometrist’s concern and the need for further evaluation.

The scenario involves a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the macula. The initial diagnostic steps, including visual acuity and slit lamp examination, have ruled out anterior segment issues. The mention of metamorphopsia and reduced central visual acuity, coupled with the observation of drusen and pigmentary changes in the macula during fundus examination, strongly suggests age-related macular degeneration (AMD). For coding purposes, the primary diagnosis would be AMD. ICD-10-CM codes for AMD are found in category H35.3-. Specifically, H35.31 refers to “Age-related macular degeneration.” Further specificity is required based on whether it is dry or wet AMD, and if there is associated geographic atrophy or neovascularization. Given the description of pigmentary changes and drusen, “Age-related macular degeneration, unspecified” (H35.319) or a more specific code if the type is definitively identified (e.g., H35.311 for dry, H35.321 for wet) would be appropriate. However, the question asks for the most encompassing and fundamental diagnostic code reflecting the observed pathology. The presence of drusen and pigmentary changes points towards the early or intermediate stages of AMD. The CPT code for the dilated fundus examination is 92250 (Fundus photography with or without optical coherence tomography, and with or without angiography). If OCT was performed, it would be coded separately (e.g., 92134 for OCT of the posterior segment). The question, however, focuses on the diagnostic coding for the condition itself. The most accurate ICD-10-CM code reflecting the described macular changes, without further specification of wet or dry, is H35.319. This code signifies “Age-related macular degeneration, unspecified eye.” The explanation of why this code is chosen involves understanding the progression of AMD, where drusen and pigmentary changes are hallmark signs. The paraoptometric coder’s role is to accurately translate these clinical findings into standardized diagnostic codes, ensuring proper reimbursement and medical record documentation. This requires a thorough understanding of the ICD-10-CM coding structure and its application to various ophthalmic conditions encountered at institutions like Certified Paraoptometric Coder (CPOC) University.

The scenario describes a patient presenting with symptoms indicative of a specific ocular condition. The paraoptometric coder must identify the most appropriate ICD-10-CM code based on the documented findings. The patient exhibits progressive, bilateral vision loss, particularly in the central visual field, and the ophthalmologist’s notes mention drusen deposits and geographic atrophy in the macula. These findings are pathognomonic for age-related macular degeneration (AMD). Specifically, the presence of geographic atrophy signifies the advanced, “dry” form of AMD. The ICD-10-CM coding system requires specificity. For AMD, the primary codes are within the H35.3 category. H35.31 refers to “Age-related macular degeneration.” Further subcategories refine the type and stage. H35.311 denotes “Age-related macular degeneration, right eye,” H35.312 for the left eye, and H35.313 for “Age-related macular degeneration, bilateral.” Given the bilateral nature of the vision loss and the documented atrophy in both maculae, H35.313 is the most accurate and comprehensive code. Other options are less precise or describe different conditions. H35.32 refers to “Other macular degeneration,” which is not specific enough. H35.33 relates to “Macular degeneration, unspecified,” lacking the detail of bilateral involvement and atrophy. H35.34 pertains to “Drusen of macula,” which is a precursor or associated finding but not the definitive diagnosis of advanced AMD with atrophy. Therefore, H35.313 accurately captures the bilateral geographic atrophy of the macula, aligning with the clinical presentation and the advanced stage of the disease.

The scenario describes a patient presenting with symptoms indicative of a posterior segment pathology, specifically affecting the macula. The initial examination reveals reduced visual acuity and metamorphopsia, classic signs of macular dysfunction. The subsequent OCT scan confirms the presence of subretinal fluid and drusen, which are hallmarks of age-related macular degeneration (AMD), particularly the wet form. Given the patient’s age and the OCT findings, the most appropriate ICD-10-CM code would reflect this diagnosis. The ICD-10-CM coding system requires specificity. While “macular degeneration” is a general term, the findings point towards a specific type. The presence of subretinal fluid suggests exudative or neovascular AMD. Codes within the H35.3 category are used for diseases of the macula and posterior pole. Specifically, H35.31 refers to “Age-related macular degeneration.” Further subdivision is necessary. H35.311 denotes “Age-related macular degeneration, right eye,” H35.312 for the left eye, and H35.319 for unspecified eye. Since the OCT findings are described without specifying which eye was scanned, and the symptoms are presented generally, the most accurate initial coding would be for unspecified eye if the laterality isn’t definitively established from the provided information. However, the question implies a focus on the *type* of macular degeneration. H35.31 is the base code for age-related macular degeneration. The presence of fluid and drusen strongly suggests the exudative form, which is often coded under H35.32, “Exudative age-related macular degeneration.” If the documentation specified “wet” AMD, this would be the correct path. Without explicit mention of “wet” or “exudative,” but with clear OCT evidence of fluid, H35.32 is the most precise choice reflecting the pathological findings. If the scenario had indicated only drusen without fluid, a code from H35.33 (nonexudative macular degeneration) might be considered, but the fluid presence overrides this. Therefore, H35.32, “Exudative age-related macular degeneration,” is the most fitting diagnosis code for the described clinical presentation and OCT findings, assuming the documentation supports this level of specificity.

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology, specifically affecting the macula. The optometrist performs a comprehensive examination, including visual acuity, slit-lamp biomicroscopy, and optical coherence tomography (OCT). The OCT reveals subretinal fluid and drusen, classic indicators of age-related macular degeneration (AMD). The patient’s visual acuity is significantly reduced in the affected eye, and there are no signs of anterior segment disease or optic nerve compromise. When coding this encounter for billing and reimbursement purposes at Certified Paraoptometric Coder (CPOC) University, the primary diagnosis must accurately reflect the identified pathology. The ICD-10-CM coding system is used for diagnostic coding. Given the OCT findings of subretinal fluid and drusen, and the clinical presentation, the most appropriate diagnosis code would relate to wet (exudative) age-related macular degeneration. Specifically, the presence of subretinal fluid points towards the exudative form. The ICD-10-CM code H35.3111 accurately captures “Wet macular degeneration, right eye.” If the findings were bilateral, a code for both eyes would be selected. The explanation of the findings on OCT, such as subretinal fluid and drusen, directly supports this diagnostic classification. The optometrist’s documentation of reduced visual acuity and the location of the pathology within the macula further solidify this diagnosis. The coding professional’s role is to translate these clinical findings into the correct alphanumeric code for accurate reimbursement and statistical tracking, adhering to the rigorous standards emphasized at Certified Paraoptometric Coder (CPOC) University.

The scenario describes a patient presenting with symptoms indicative of a specific ocular condition. The paraoptometric coder must identify the most appropriate ICD-10-CM code based on the documented findings. The patient’s history includes progressive vision loss, particularly in the central visual field, and the presence of drusen noted during fundus examination. These are classic indicators of age-related macular degeneration (AMD). Specifically, the description points towards a dry form of AMD, characterized by the gradual accumulation of drusen and pigmentary changes in the macula. The ICD-10-CM coding system requires specificity when possible. For AMD, the relevant chapter is H35, “Other disorders of retina and choroid.” Within this chapter, H35.3 pertains to “Degeneration of macula and posterior pole.” Further subdivision is necessary to distinguish between dry and wet AMD. H35.31 refers to “Age-related macular degeneration,” and H35.311 specifies “Age-related macular degeneration, right eye,” H35.312 for the left eye, and H35.313 for both eyes. Given the bilateral nature of the symptoms described (“both eyes”), H35.313 is the most accurate code. The other options are less precise or represent different conditions. H40.9 (Glaucoma, unspecified) is incorrect as glaucoma is not indicated. H52.13 (Myopia, bilateral) relates to refractive errors, not macular degeneration. H35.89 (Other specified disorders of retina and choroid) is a less specific code and should only be used when a more precise code is not available, which is not the case here. Therefore, the accurate coding for bilateral age-related macular degeneration, as suggested by the clinical presentation, is H35.313.

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology, specifically affecting the macula. The initial comprehensive eye examination, including visual acuity and slit-lamp biomicroscopy, revealed no significant anterior segment findings. However, the subsequent Optical Coherence Tomography (OCT) scan is crucial for diagnosing conditions like age-related macular degeneration (AMD) or diabetic macular edema. Given the patient’s age and the OCT findings of subretinal fluid and drusen, the most appropriate ICD-10-CM code for the diagnosis would reflect age-related macular degeneration. The specific code for dry AMD, which often precedes wet AMD and is characterized by drusen, is H35.31-. The presence of subretinal fluid indicates a transition to or presence of wet AMD, which is coded under H35.32-. However, without explicit mention of neovascularization or hemorrhage, and given the description of drusen, a code indicating the presence of macular degeneration with other macular degeneration is appropriate. H35.30 (Unspecified macular degeneration) is too general. H35.31 (Age-related macular degeneration, dry) and H35.32 (Age-related macular degeneration, wet) are specific. Since the OCT shows drusen and fluid, it points towards a more advanced stage, potentially wet AMD or a combination. The most precise coding, considering the provided information and the need for specificity in ICD-10-CM, would be to capture the presence of macular degeneration with associated changes. H35.35 (Age-related macular degeneration, unspecified, with geographic atrophy) is incorrect as atrophy is not mentioned. H35.36 (Age-related macular degeneration, unspecified, with neovascularization) is also not explicitly stated. Therefore, H35.32 (Age-related macular degeneration, wet) is the most fitting code if neovascularization is implied by the fluid, or a code that encompasses both dry and wet features if available. However, focusing on the provided information, H35.32 is the most direct representation of the observed pathology (fluid suggesting neovascularization).

The scenario involves a patient presenting with symptoms suggestive of a posterior segment pathology. The paraoptometric coder must accurately translate the clinical findings into appropriate ICD-10-CM codes. The provided information indicates a diagnosis of age-related macular degeneration (AMD) affecting the right eye, specifically the dry form. The ICD-10-CM coding system requires specificity regarding the laterality and the type of macular degeneration. For age-related macular degeneration, the primary code category is H35.3. Within this category, H35.31 refers to “Age-related macular degeneration.” Further specificity is needed for the type of AMD. H35.311 denotes “Age-related macular degeneration, dry, right eye.” The presence of drusen, which are yellowish deposits under the retina, is a hallmark of dry AMD and does not necessitate a separate diagnosis code unless they are the primary reason for the visit or are specified as being of a particular size or type that warrants additional coding. Given the description, the most accurate and specific code reflecting the diagnosed condition is H35.311. Other codes might be considered if additional conditions were present or if the documentation supported a different stage or type of AMD, but based solely on the provided details, H35.311 is the correct selection.

The scenario describes a patient presenting with symptoms indicative of a posterior uveitis, specifically affecting the macula. The initial diagnostic workup includes Optical Coherence Tomography (OCT) and fluorescein angiography (FA). The OCT reveals intraretinal fluid and subretinal fluid, characteristic of macular edema. The FA demonstrates punctate hyperfluorescence in the early phase, progressing to a diffuse leakage pattern in the late phase, consistent with choroidal neovascularization (CNV) secondary to inflammation. For coding purposes, the primary diagnosis is the inflammatory condition of the uveitis. Given the macular involvement and the presence of subretinal fluid and leakage on FA, the most appropriate ICD-10-CM code would reflect this. Uveitis is a broad category, and specifying the type and location is crucial. Posterior uveitis affecting the macula, especially with evidence of neovascularization, points towards a more specific diagnosis. Considering the findings, the presence of intraretinal and subretinal fluid, along with leakage on FA, strongly suggests a component of macular edema. While uveitis is the underlying inflammatory process, the manifestation of fluid accumulation and potential neovascularization requires careful coding. The ICD-10-CM system provides codes for various types of uveitis and their complications. A posterior uveitis with macular involvement, particularly when associated with fluid accumulation and potential neovascularization, would fall under codes related to inflammatory conditions of the posterior segment. The presence of subretinal fluid and leakage on angiography, indicative of potential choroidal neovascularization or significant inflammatory exudation impacting the macula, necessitates a code that captures this severity and location. The correct approach involves identifying the most specific ICD-10-CM code that accurately reflects the diagnosed condition. In this case, the findings of posterior uveitis with macular edema and evidence of leakage on angiography are best represented by a code that encompasses these elements. The code H30.9 (Chorioretinal inflammation, unspecified) is too general. H35.31 (Age-related macular degeneration) is incorrect as the etiology is inflammatory, not age-related. H40.9 (Glaucoma, unspecified) is irrelevant. The most accurate code, reflecting posterior uveitis with macular involvement and the observed fluid accumulation and leakage, is H30.2 (Posterior uveitis). This code encompasses the inflammatory process affecting the posterior segment of the eye, which, in this scenario, manifests with macular edema and angiographic leakage, implying significant involvement of the choroid and retina.