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Encounter for examination of eyes and vision following failed vision screening with abnormal findings

ICD10CM code

Name of the Condition

  • Common name: Failed Vision Screening with Abnormal Findings
  • Technical/medical term: Encounter for examination of eyes and vision following failed vision screening with abnormal findings (ICD-10-CM Code: Z01.021)

Summary

This condition refers to a follow-up medical examination for individuals who have not passed a vision screening. This examination aims to further investigate and diagnose any underlying eye or vision abnormalities that may have been indicated by the initial screening results.

Causes

  • A failed vision screening can result from various factors, such as refractive errors, ocular diseases (e.g., cataracts, glaucoma), or other underlying health conditions that affect vision.

Risk Factors

  • Family history of eye disorders
  • Advancing age
  • Pre-existing medical conditions like diabetes or hypertension
  • Prolonged exposure to screens or harsh lighting
  • Inadequate eye protection in hazardous environments

Symptoms

  • Blurred or decreased vision
  • Difficulty focusing or seeing at certain distances
  • Eye strain or discomfort
  • Frequent headaches
  • Abnormal findings in standard vision tests

Diagnosis

  • Comprehensive eye examination
  • Visual acuity tests
  • Retinal examination
  • Refraction assessment
  • Specialized tests (e.g., tonometry for glaucoma)

Treatment Options

  • Prescription eyeglasses or contact lenses to correct refractive errors
  • Medications or eye drops for conditions like glaucoma
  • Surgical interventions for cataracts or other ocular diseases
  • Vision therapy exercises to improve focusing abilities

Prognosis and Follow-Up

  • With appropriate treatment, most vision abnormalities can be managed effectively, improving overall visual function.
  • Regular follow-up appointments are crucial to monitor changes in vision and adjust treatments as needed.

Complications

  • Untreated vision problems can lead to chronic eye strain, headaches, or further deterioration in vision.
  • In children, untreated vision issues can affect development and learning.

Lifestyle & Prevention

  • Routine eye exams for early detection
  • Protective eyewear for activities that pose a risk to the eyes
  • Limiting screen time and ensuring proper lighting
  • Maintaining a healthy lifestyle, including a balanced diet rich in eye-friendly nutrients

When to Seek Professional Help

  • Sudden changes in vision
  • Persistent eye pain or discomfort
  • Visual disturbances, such as flashes of light or floaters
  • Difficulty seeing at night or in low-light conditions

Additional Resources

  • American Academy of Ophthalmology (aao.org)
  • Prevent Blindness (preventblindness.org)
  • National Eye Institute (nei.nih.gov)

Tips for Medical Coders

  • Ensure the code Z01.021 is used specifically for cases where a follow-up examination is conducted after a failed vision screening with abnormal findings.
  • Be precise in documenting any specific abnormalities identified during the examination.
  • Avoid coding errors by verifying the accuracy and completeness of clinical documentation before coding.

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