Glaucoma Suspect, High-Risk vs Low-Risk?

As a scribe we try to think ahead for the benefit of the physician during the exam. A good scribe is a true multitasker, and overtime can almost read the physician’s mind. But whether you are a new or established scribe, new changes in medical billing will keep you on your toes.

In this blog we will review the difference between a high-risk glaucoma suspect versus low-risk. Prior to ICD-10 the distinction between high-risk or low-risk did not necessarily need to be made. And although ICD-10 is no considered a new system it can be tricky to identity which diagnosis code is best suited for the exam findings.

First and foremost, the physician will determine the correct diagnosis codes and exam codes for the visit. But as a scribe we can try to input a diagnosis code for the physician to review prior to signing the chart. To do so accurately, it is important to understand what makes a patient either high or low risk.

The main difference between a high-risk glaucoma suspect and a low-risk glaucoma suspect is the number of risk factors the patient has. The risk factors for ICD-10 glaucoma suspect codes are as follows: African American or Hispanic race, Family history of glaucoma in a first-degree relative, thin central corneal thickness, high IOP, pseudoexfoliation or pigment dispersion syndrome. To be considered a high-risk glaucoma suspect the patient must have 3 or more of these risk factors. If the patient has fewer  than 3 risk factors then they are considered low risk. A work-up technician’s role in the exam is crucial when determining if a patient is high- risk or low-risk. The technician has already documented the family history, IOP, and , if ordered, has taken a pachymetry reading prior to the physician starting the exam. As a scribe you can review the charting as well as document the doctors finding to assist in proper ICD-10 code decision making.

For more information on scribe and technician training please contact Eyetechs at (617) 429-6155

Source: https://www.aao.org/practice-management/coding/icd-10-cm

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