Documentation Dissection
NEW PATIENT VISIT OAF |1|
Oriented to time, place, person: Yes
Mood and affect appropriate: Yes
Chief Complaint: New patient that has been diagnosed with possible shingles in the right. She states that her |2| right eye is painful,
itching and sore. She was seen this morning and Dr. X is her PCP.
Past Ocular History:
OAF Testing:
Eye/Systemic Medications: None
Allergies: CODEINE, TEGRETOL
Review of Systems:
Constitutional: Positive
Eyes: Positive
Ears, Nose, Mouth, Throat: Negative
Cardiovascular: Positive
Respiratory: Positive
Gastrointestinal: Negative
Genitourinary: Negative
Musculoskeletal: Positive
Skin and/or breasts: Negative
Neurological: Positive
Psychiatric: Negative
Endocrine: Negative
Hematologic/Lymphatic: Positive
Allergic/Immunologic: Positive
Past Medical History:
Rheumatoid Arthritis
Fibromyalgia
Depression
Diabetes-borderline
Osteoarthritis
Past Surgical/Procedure History:
Gallbladder
Tonsils
Breast reduction
Part of thyroid taken out
Carpal tunnel
1
Past Hospitalizations History:
Social History:
Marital Status: Single
Occupation; Unemployed
Smoking: Non-Smoker.
Alcohol: Abstains from using alcohol at this time
Caffeine: Yes 2 daily
Family History:
Arthritis
Diabetes
Cancer
Ocular Exam |3|:
VA: without glasses
Right: 20/25-1
PH: 20-2
Left: 20/25
PH: NI
J-
Near:
Near:
AR:
Right
Left
Manifest Refraction:
T Tonopen: 15 OU
Pupils: Equal, round, reactive to light and accommodation
APD: No Right:
APD: No Left:
Motility: Full
Confrontational VF: Full OU
Dilation @: with
SLIT LAMP EXAM:
Ext lids/Lashes: Right: open rash above eyelid, lesion lateral Left: normal
Conjunctiva: Right: bulbar and palpebral conjunctiva are clear, sclera white. Left: bulbar and palpebral conjunctiva are clear, sclera
white
Cornea: Right: PEE Left: PEE
Anterior Chamber: Right: Deep and quiet Left: Deep and quiet
2
Iris: Right: round Left: round
Lens: Right: Clear Left: Clear
Dilated Fundus Exam:
Not performed
My key findings of the History of Present Illness and Medical Decision Making are summarized below:
CC/HPI:
Here for possible Shingles infection, rash developed a couple days ago above her right eye, and now her right eye feels irritated and
itchy. Vision is stable, no pain, redness or tearing.
Assessment/Plan:
Shingles Dermatitis: Start oral Acyclovir 800 gm 5x/dy for 10 days |4|.
Blepharitis due to herpes zoster: Discussed using lid hygiene and warm compresses, Start Bacitracin ophthalmic ointment at night |4|.
Dry Eye Syndrome: Start preservative free artificial tears OU |5|
FU 2 weeks
_____________________________________________________________
|1| New patient—Ophthalmology Examination.
|2| Diagnosis of possible shingles—right eye.
|3| Ocular exam is not comprehensive, it meets the guidelines of intermediate.
|4| Final diagnosis.
|5| Abbreviation for each eye or bilateral.
_____________________________________________________________
What are the CPT® and ICD-10-CM codes reported?
CPT® Code: 92002
ICD-10-CM Codes: B02.39, H04.123
Rationales:
CPT®: In the Alphabetic Index look for Ophthalmology, Diagnostic/Eye Exam/New Patient which directs you to 92002–92004.
According to the guidelines for Ophthalmology coding of E/M service, located in the Medicine section, this constitutes as an
Intermediate ophthalmological visit, as the patient did not receive a general evaluation of the complete visual system and 92002
Ophthalmological services medical examination and evaluation with initiation and continuation of diagnostic and treatment
program; intermediate, new patient is selected.
ICD-10-CM: Look in the ICD-10-CM Alphabetic Index for Shingles see Herpes/zoster/eye (lid) leading to B02.39. ICD-10-CM
B02.39 Other Herpes Zoster eye disease. In the ICD-10-CM Alphabetic Index look for Blepharitis/Herpes zoster also leading to
B02.39. Next in the ICD-10-CM Alphabetic Index look for Syndrome/dry eye which directs you to code H04.12-. A 6th character of
3 is used for the both eyes (OU). Verify code selection in the Tabular List.
