An ophthalmology visit documents primary open-angle glaucoma, bilateral, moderate stage. Which coding approach best reflects ICD-10-CM specificity expectations?
Select an answer to reveal the explanation.
Short Explanation
Glaucoma coding likes the full address: type, which eye(s), and how far along it is. If the ophthalmology note already hands you bilateral moderate primary open-angle glaucoma, don’t shrug and drop an unspecified placeholder.
Full Explanation
ICD-10-CM glaucoma categories commonly require type, laterality, and stage for complete code assignment. When the physician documents primary open-angle glaucoma that is bilateral and moderate stage, those elements should be reflected rather than defaulting to unspecified glaucoma. Blindness codes are not automatic substitutes for glaucoma documentation.