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Question: An established 42-year-old patient presents to a family medicine office with two days of localized redness, tenderness, and swelling along the right upper eyelid. The patient reports mild eye irritation but denies trauma, vision changes, photophobia, fever, or pain with eye movement. Examination shows a small, tender pustule at the right upper eyelid margin with localized erythema. Visual acuity is unchanged, extraocular movements are intact, and there is no diffuse eyelid edema or conjunctival discharge. The physician diagnoses an external hordeolum (stye), recommends warm compresses and eyelid hygiene, and instructs the patient to return for worsening swelling, fever, eye pain, or visual symptoms. Which encounter and ICD-10-CM codes should the practice report?

Kansas Subscriber

Answer: For the encounter, report the appropriate established patient office/outpatient evaluation and management (E/M) service based on the documented medical decision making (MDM) or total time. Based on the information provided, the encounter may support a low-level established patient E/M service, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.), if the physician's documentation supports low MDM.

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If you look up “stye” in the Alphabetic Index of your ICD-10-CM code book, you’ll be directed to “Hordeolum,” where you can find H00.011 (Hordeolum externum right upper eyelid) to report for the diagnosis.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC