Glaucoma Documentation Guide
Progressive optic neuropathy characterized by optic nerve damage and visual field loss, often associated with elevated intraocular pressure.
ICD-10 Codes: H40.10, H40.11, H40.12, H40.13, H40.20, H40.21, H40.22, H40.23, H40.30, H40.9
Common Symptoms
- Gradual peripheral vision loss
- Elevated intraocular pressure
- Optic disc cupping
- Halos around lights
- Often asymptomatic early
Key Documentation Elements
- Glaucoma type (open-angle, angle-closure, normal tension)
- IOP measurements and target pressure
- Cup-to-disc ratio and optic nerve assessment
- Visual field (HVF) results and progression analysis
- Current medical therapy and surgical intervention history
Documentation Challenges
- Documenting IOP measurements and target pressure
- Recording visual field test results and progression
- Capturing OCT nerve fiber layer analysis trends
- Tracking medication compliance across multiple eye drops
Billing Considerations
- Type and stage coding (H40.11 primary open-angle, H40.20 angle-closure)
- Laterality and stage (mild, moderate, severe, indeterminate)
- OCT and visual field testing procedure billing
Frequently Asked Questions
How is glaucoma coded by type and severity?
Glaucoma codes include type (H40.11 open-angle, H40.20 angle-closure), laterality, and stage (mild/moderate/severe). Scribeable maps your documented IOP, disc findings, and visual field results to the precise code.
How does Scribeable support glaucoma monitoring documentation?
Scribeable captures IOP measurements, visual field summaries, OCT findings, medication adherence, and target pressure assessments from your encounter for longitudinal glaucoma management documentation.