Good physician documentation is the lens you need to see through in order to correctly code blindness and low vision conditions.
For example, category-level tabular instruction at H54.- (Blindness and low vision) requires you to "code first" the underlying cause of the patient’s blindness.
And, most codes within this category require a high level of detail regarding the category of vision loss, whether one or both eyes are affected and to what degree. For example, code H54.52A1 corresponds to Low vision left eye category 1, normal vision right eye.
Codes for blindness and low vision conditions are found in Chapter 7 (Diseases of the Eye and Adnexa), specifically within the section "Visual disturbances and blindness" where categories H53.- (Visual disturbances) and H54.- are housed.
A search in the alphabetical index under the main term "blindness" will direct the coder to the H54.- category. You also may search under "low" or "loss" and then scroll to "vision" and that will also lead you to codes within the H54.- category.
You will find more specificity if you scroll down and look under additional terms that are indented under the main term, such as those specifying laterality, when there is a distinction between visual acuity in different eyes and when blindness is defined in legal terms.
For example, searching under "blindness, legal (both eyes) (USA definition)" leads directly to H54.8 (Legal blindness, as defined in USA).
Following a recent DecisionHealth webinar about mastering OASIS-C2, agencies asked questions of expert Ann Rambusch, MSN, HCS-D, HCS-O, RN, president of Rambusch3 Consulting in Georgetown, Texas. Here are some of her answers.
Question: For skin pressure ulcers, do we downgrade them as they heal or not with the new OASIS-C2 requirements? We were told in past training if it starts at a Stage 4 and heals throughout care, we code it what it is as it heals. So, a Stage 4 could be down coded to a Stage 3, 2, 1 as it heals.
Answer: Do not "down code" or reverse stage a pressure ulcer as a way to document healing. Reverse staging does not accurately characterize what is physiologically occurring as the ulcer heals. Over time as the Stage 4 pressure ulcer heals and contracts it becomes less deep, wide and long. The tissues (muscle fat, dermis) that were lost due to the ulcer are never replaced with the same type of tissue. Even though the wound has granulated almost completely (i.e., it’s 95% granulated), the ulcer is not reverse staged. The ulcer may have healed almost up to the surface of the epithelium, but it is still a Stage 4 ulcer. Clinical standards require that the ulcer continue to be documented as a Stage 4 until it has healed. (Chapter 3, M1307 (Oldest Stage 2 Pressure Ulcer), OASIS-C2 Guidance Manual, 1/2017)
Q: What do we do when a muscle flap fails, is it now a pressure ulcer again or does it remain a surgical site forever? So, every flap graft that fails, [do] we eat the failed area as a new pressure area when it now becomes a pressure area again?
A: On the OASIS, a pressure ulcer treated with a muscle flap is no longer considered a pressure ulcer. It is reported as a surgical wound. If the muscle flap used to treat the pressure ulcer is not healing or the flap begins to fail, the wound should be considered a complicated surgical wound. Continue to report the wound as a surgical wound on M1340 (Surgical Wound).
If the muscle flap heals (edges are completely re-epithelialized and the incision is clean, dry and closed with no signs or symptoms of infection for at least 30 days) this becomes a scar and is no longer reported as a surgical wound. If a new lesion due to pressure forms on the area that has healed, it is reported as a new pressure ulcer and staged accordingly.
When you have a flap that is used to treat a pressure ulcer, remember the pressure ulcer was removed (excised) completely and the flap becomes the surgical wound. That wound heals, it goes through epithelialization and becomes a scar. If a pressure ulcer then forms on top of that, that is considered a new pressure ulcer.
An elderly male patient is admitted to home health following an intertrochanteric fracture of the left hip sustained from falling down stairs. The patient developed a stage 3 pressure ulcer to his left heel during the inpatient stay. Documentation indicates he is legally blind due to bilateral severe stage chronic angle-closure glaucoma. The physician ordered nursing and physical therapy for continued aftercare of the fracture and management of the pressure ulcer.
Code the scenario:
|Primary and Secondary Diagnoses||M1025
|M1021a: Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing||S72.142D|
|M1023b: Pressure ulcer of left heel, stage 3||L89.623|
|M1023c: Chronic angle-closure glaucoma, bilateral, severe stage||H40.2233|
|M1023d: Legal blindness, as defined in USA||H54.8|
|M1023e: Fall (on) (from) unspecified stairs and steps, subsequent encounter||W10.9xxD|
- The instruction located under H54.- blindness and low vision state, "Code first any associated underlying cause of the blindness. Since documentation indicates bilateral chronic angle-closure glaucoma is the underlying cause of the patient’s legal blindness, the glaucoma code is sequenced prior to the code for legal blindness.
- The U.S. definition of legal blindness differs from the WHO definition, therefore, H54.8 is used to capture legal blindness within the United States.