ICD-10 Coding for Dry Eye Disease(H04.121, H04.122)
Complete ICD-10-CM coding and documentation guide for Dry Eye Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dry Eye Disease
H04.12-H04.129Primary Range
Dry eye syndrome
This range covers the primary codes for dry eye syndrome, including laterality.
Keratoconjunctivitis sicca, not specified as Sjögren's
This range includes codes for keratoconjunctivitis sicca without Sjögren's syndrome.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H04.121 | Dry eye syndrome of right lacrimal gland | Use when dry eye syndrome is confirmed in the right eye with clinical tests. |
|
| H04.122 | Dry eye syndrome of left lacrimal gland | Use when dry eye syndrome is confirmed in the left eye with clinical tests. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for dry eye disease
Essential facts and insights about Dry Eye Disease
Primary ICD-10-CM Codes for dry eye disease
Decision Criteria
clinical Criteria
- Tear breakup time ≤5 seconds
documentation Criteria
- Document laterality and specific test results
Applicable To
- Dry eye syndrome affecting the right eye
Excludes
- Keratoconjunctivitis sicca (H16.22-)
Clinical Validation Requirements
- Tear breakup time ≤5 seconds
- Schirmer test ≤5mm/5min
Code-Specific Risks
- Ensure laterality is documented to avoid unspecified coding.
Coding Notes
- Ensure all clinical tests are documented to support the diagnosis.
H04.122 - Dry eye syndrome of left lacrimal gland
Use when dry eye syndrome is confirmed in the left eye with clinical tests.
Applicable To
- Dry eye syndrome affecting the left eye
Excludes
- Keratoconjunctivitis sicca (H16.22-)
Clinical Validation Requirements
- Tear breakup time ≤5 seconds
- Schirmer test ≤5mm/5min
Coding Notes
Ensure all clinical tests are documented to support the diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dry Eye Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H04.121.
Impact
Clinical: Leads to incomplete clinical records., Regulatory: Increases risk of audits and compliance issues., Financial: May result in claim denials or reduced reimbursement.
Mitigation Strategy
Always specify right or left eye in documentation., Use templates that prompt for laterality.
Impact
Reimbursement: Unspecified codes may lead to claim denials., Compliance: Increases audit risk due to lack of specificity., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Always document and code laterality to avoid unspecified codes.
Impact
Using unspecified codes increases audit risk.
Mitigation Strategy
Ensure documentation supports specific coding, including laterality.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Dry Eye Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dry Eye Disease
Use these documentation templates to ensure complete and accurate documentation for Dry Eye Disease. These templates include all required elements for proper coding and billing.
Ophthalmology progress note for dry eye syndrome
Specialty: OphthalmologyRequired Elements
- Chief complaint
- Review of systems
- Objective test results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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