Abstract: In the IMPRESSION/RETINA - VASCULAR window, document diabetes and retinopathy. You must select a severity for the observation you recorded. Possible selections include, but are not limited to, the following: Open the Diagnosis/Procedure Coding window to check if the codes are now autocoding.
If CPT II code 2021F is not autocoding, first check to make sure that you have enabled PQRS autocoding. If you enable PQRS autocoding, all PQRS-applicable diagnoses and procedures appear in green text in the exam windows.
If CPT II code 2021F is still not autocoding, follow the instructions below:
- In a patient's exam, click the Exam - Special Tests tab.
- Click the Examination category bar.
- Select the Retina - Vascular check box and click Process.
- Select the RETINAL VASCULAR DISORDERS and Impression check boxes.
- In the RETINAL VASCULAR window, select one of the following check boxes to indicate that you documented the macular edema:
- Macular edema WNL
- Edema
- Macular elevation
- Severity, Mild
- Moderate
- Severe
Note: In order for CPT II code 2021F to autocode, you must document the presence/absence of macular edema and the severity of the condition. If you do not record macular edema or the severity, then you must manually record CPT II code 2021F.