Reporting and Coding Central Serous Chorioretinopathy (CSR)

by | Nov 15, 2018 | Medical Coding News, Resources | 0 comments

Central serous retinopathy (CSR) is an eye condition in which fluid builds up underneath the retina in the eye, which affects the vision. The sudden buildup of fluid can cause a partial detachment of the retina. The retina is a thin, sensitive layer of tissue in the back of the eye which converts light into neural signals that are sent to the brain. The retina helps you recognize the images you see. Also known as central serous chorioretinopathy (CSC), this condition can cause sudden or gradual vision loss as the central retina (central area called the macula) detaches. Patients suffering from this condition often detect a circular grey patch in their vision. They may also notice distortion and the objects appear smaller in the affected eye. In some cases, the condition corrects by itself without requiring any specific medical treatment and the person will regain or improve their vision after a short period. The fluid build-up in the retina behind the eye may drain away on its own. However, people who happen to experience even a slight change in their vision should consult their doctor immediately as greater will be the odds of having a full recovery. As ophthalmology medical billing and coding is challenging, it is important for hospitals and medical coding companies to stay up-to-date with the latest medical codes related to this condition to ensure accurate claim submissions.

Regarded as the fourth most common retinopathy, CSR generally affects young to middle-aged people with no previous signs or symptoms of retinal disorder. It is more common among men than women, who represent about 85-90 percent of the cases. The average age of onset of the disease is mid 30s, but it ranges from the late 20s to late 50s as well. The exact cause of this condition is not known. However, reports suggest that it tends to occur in people who are highly work-driven, who work for long hours or have high levels of stress for any reason. People who use oral steroids are at a higher risk of developing this condition. In addition, lack of sleep also seems to play an active role.

Some Common Symptoms to Notice

Serous Chorioretinopathy generally affects one eye. However, it is possible that a person may develop the condition in each eye at separate points throughout their life. One of the most common symptoms associated with this condition is blurry vision. Other additional symptoms include –

  • A dark spot in the center of vision
  • Objects appearing farther away
  • Straight lines may appear crooked
  • White objects may have a brownish or grayish tinge, making them appear dull

However, this condition may not always produce symptoms. The changes in vision may mainly depend on the specific area wherein the fluid build-up is located. If the affected part does not include areas around the macula, patients can continue to view things clearly with minute details. The macula is the part of the retina responsible for differentiating the finer details of an object a person in viewing. In such cases, a person may suffer from the eye condition, but they may not able to know the same, as they do not experience any symptoms.

Need for Accurate Diagnosis and Treatment

Any visible change in vision can be an indication of an underlying retinal condition. Eye conditions can degenerate very quickly and if left untreated can lead to permanent vision loss. As an initial diagnosis of CSR, ophthalmologists will conduct a detailed examination of the patient’s eye. Physicians will be asked several questions to analyze the symptoms and find out the exact causes for these symptoms. Several diagnostic imaging tests like – Ophthalmoscopy, Optical coherence tomography (OCT) and Fluorescein angiography will be done to look different layers of the retina.
As most cases of CSR will resolve on its own, no specific treatment is required for the same. In such cases, an eye specialist will carefully monitor the patient’s eye to find out whether the fluid is draining. However, no other specific intervention will be required as the fluid drains away over the course of several weeks.

On the other hand, if the fluid does not drain away on its own, several treatment modalities will have to be administered. Treatment modalities include – thermal laser treatment, photodynamic treatment, medications (like anti-vascular endothelial growth factor medication {anti-VEGF}), andstopping the intake of corticosteroids and other drugs containing steroids. In addition, incorporating key lifestyle changes like – reducing overall stress levels (through exercise); getting adequate sleep (for at least 7 hours), avoiding alcoholic drinks and reducing the intake of caffeine can also help prevent the occurrence of CSR.

Ophthalmologists or other eye specialists treating CSR will have to report the correct diagnostic and procedural codes on the medical claims to obtain due coverage. Medical billing and coding services offered by reliable providers ensure that the correct ICD-10 and CPT codes such as the following are used for medical billing purposes –

ICD-10 Codes

H35.71 – Central serous chorioretinopathy

  • H35.711 – Central serous chorioretinopathy, right eye
  • H35.712 – Central serous chorioretinopathy, left eye
  • H35.713 – Central serous chorioretinopathy, bilateral
  • H35.719 – Central serous chorioretinopathy, unspecified eye

CPT Codes

  • 67101 – Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, including drainage of sub retinal fluid, when performed
  • 67105 – Repair of retinal detachment, 1 or more sessions; photocoagulation, including drainage of sub retinal fluid, when performed

Although Central serous chorioretinopathy (CSR) can be damaging to your vision, most people have a relatively good prognosis with no treatment at all. Majority of people regain vision within 1-2 months. In other cases, some people experience problems with vision, but it will be very mild. Patients who recover from CSR must discuss with physicians in detail whether it’s safe to consume medications containing steroids. Physicians must look into different treatments for other health problems that you had been treating with steroids. The recurrence of this retinal condition may demand more aggressive treatment than the first time.

Medical billing and coding for Central serous chorioretinopathy (CSR) can be difficult. By outsourcing medical coding to a reliable medical billing and coding outsourcing company (that offers the services of AAPC-certified coding specialists), healthcare practices can ensure correct and timely medical billing and claims submission.