H40.60X4

Here is a detailed guide note for H40.60X4, formatted as clean text for your reference.

H40.60X4: Glaucoma secondary to drugs, unspecified eye, indeterminate stage

Description

• Definition: Glaucoma caused by a reaction to a drug (e.g., corticosteroids), where the specific affected eye (right or left) is not documented and the stage of the disease cannot be clinically determined.
• 7th Character “4” (Indeterminate Stage): This specific character should be used only when the stage of glaucoma cannot be determined due to clinical limitations (e.g., media opacity like a dense cataract preventing a view of the optic nerve, or the patient is unable to perform visual field testing due to cognitive impairment). It is distinct from “Unspecified stage” (“0”), which means the information is simply missing from the note.
• “Unspecified Eye”: This code indicates laterality is missing. This is a high audit risk and should be avoided if possible by querying the provider for the correct side (Right/Left/Bilateral).

Body area

• Eye—glaucoma (intraocular pressure/optic nerve damage condition); laterality not specified (“unspecified eye”).​​

Includes / Excludes

• Includes: The H40.6 subcategory guidance includes “Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with 5th/6th character 5).”​

• Excludes1: Under the broader H40 category, Excludes1 includes absolute glaucoma (H44.51-), congenital glaucoma (Q15.0), and traumatic glaucoma due to birth injury (P15.3).​​

• Excludes2: Not shown in the available excerpt for H40.6 specifically.

Risk Adjustment (HCC) Status

• HCC Weight: No (Likely).
• Clinical Note: While specific glaucoma codes often map to HCC 124 (Exudative Macular Degeneration and Advanced/Hemorrhagic Glaucoma) or similar categories depending on the model, codes with “Unspecified Eye” are frequently excluded from risk adjustment models because they lack the necessary specificity.
• Action: To ensure accurate risk adjustment (HCC) capture, you must query the provider to specify the eye (Right/Left/Bilateral).

Coding Requirements

• Mandatory Additional Code: You must report an additional code to identify the drug causing the adverse effect.
  • Use codes from T36-T50 with a 5th or 6th character of 5 (Adverse effect).
  • Example: If caused by long-term steroid eye drops, code also T37.5X5A (Adverse effect of antiviral drugs… wait, steroids are typically T38.0X5A - Adverse effect of glucocorticoids and synthetic analogues).

Common Associated CPT Codes

• Diagnostic Testing:
  • 92083: Visual Field Examination (extended). Note: If the patient cannot perform this (justifying the “indeterminate stage”), this code might not be applicable, or a lower level (92081) might be used.
  • 92133: OCT of the Optic Nerve.
  • 76514: Corneal Pachymetry (measure corneal thickness).
• Procedures (if treated surgically):
  • 65855: Laser trabeculoplasty.
  • 66174/66175: Canaloplasty or MIGS (stent) procedures.
  • 66982: Complex Cataract Surgery (often used if the pupil is small or Peripheral anterior synechiae are present due to the drug/inflammation).

Compliance & Audit Alerts

• Laterality Rule: Payers, especially Medicare, will likely deny this claim for lack of specificity. You should always attempt to code H40.61X4 (Right), H40.62X4 (Left), or H40.63X4 (Bilateral) instead of H40.60X4.
• Documentation Support: The medical record must explicitly document why the stage is indeterminate (e.g., “Patient unable to complete HVF due to dementia” or “View of optic nerve obscured by dense cataract”). If this reasoning is missing, an auditor may downcode this to “Unspecified stage” (“0”).

Modifier	Meaning (high-level)	Common ophtho use
-25	Significant, separately identifiable E/M	E/M plus minor procedure same day
-RT	Right side	Laterality for procedures
-LT	Left side	Laterality for procedures
-50	Bilateral procedure	When the procedure is performed bilaterally
-59	Distinct procedural service	When appropriate to unbundle distinct services
-24	Unrelated E/M in postop period	Global surgery scenarios

Common CPTs used with this diagnosis (examples)

• 92004 / 92014 (comprehensive ophthalmological services, new/established patient, when documented/appropriate).​

• 99202-99205 / 99212-99215 (office/outpatient E/M, depending on the encounter).​

• 92083 (visual field exam, extended).​

• 92133 (OCT, optic nerve) and/or 92134 (OCT, retina) when medically necessary and supported.​

Example coding

Example: Provider documents “glaucoma secondary to long-term steroid use; eye not specified; stage cannot be determined today” → assign H40.60X4, and also assign an adverse effect code to identify the drug (T36-T50 with 5th/6th character 5) when applicable and supported by documentation.