Code: H40.013
Description: Open angle with borderline findings, low risk, bilateral
Context: This code is used for cases where a patient has bilateral open-angle glaucoma with borderline findings, classified as low risk.

Guidelines for Proper Use

• Specific Diagnosis for Both Eyes: Use H40.013 for patients diagnosed with bilateral open-angle glaucoma, characterized by borderline findings and deemed low risk. This diagnosis involves the optic nerve, typically without high eye pressure or other high-risk factors.
• Accurate Documentation: Ensure the healthcare provider’s documentation clearly specifies bilateral open-angle glaucoma with borderline findings and low risk. This should be based on comprehensive eye examinations, including optic nerve assessment.
• Exclusion of Other Types of Glaucoma: Do not use H40.013 for other types of glaucoma or if the condition is classified as high risk or has progressed beyond borderline findings.
• Differentiation from Unilateral Glaucoma: Be cautious not to use H40.013 for cases where only one eye is affected by open-angle glaucoma. Each eye condition should be coded accurately.
• Compliance with Coding Standards: Apply H40.013 in accordance with clinical documentation and adhere to relevant coding guidelines, including payer-specific requirements.

Common Misuses of H40.013

• Use for Other Types or Stages of Glaucoma: Misuse occurs when H40.013 is used for patients with other types of glaucoma or those at a different stage of open-angle glaucoma.
• Confusion with High-Risk Conditions: Avoid using H40.013 for cases classified as high risk or those with findings beyond the borderline stage of open-angle glaucoma.
• Application to Unilateral Conditions: Do not use H40.013 for unilateral open-angle glaucoma. It is specifically for bilateral cases.