ICD-10 Coding for Dry Eye(H04.121, H04.122, H04.123)
Complete ICD-10-CM coding and documentation guide for Dry Eye. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dry Eye
H04.12-H04.13Primary Range
Disorders of lacrimal gland
This range includes codes specific to dry eye conditions based on laterality.
Keratitis due to other causes
This range includes codes for punctate keratitis secondary to dry eye.
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 is confirmed in the right eye with specific clinical findings. |
|
| H04.122 | Dry eye syndrome of left lacrimal gland | Use when dry eye is confirmed in the left eye with specific clinical findings. |
|
| H04.123 | Dry eye syndrome of bilateral lacrimal glands | Use when dry eye is confirmed in both eyes with specific clinical findings. |
|
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 bilateral dry eye
Essential facts and insights about Dry Eye
Primary ICD-10-CM Codes for dry eye
Decision Criteria
clinical Criteria
- Presence of tear film insufficiency with specific test results.
Applicable To
- Tear film insufficiency
- Lacrimal gland dysfunction
Excludes
- Sjögren's syndrome (M35.01)
Clinical Validation Requirements
- Schirmer ≤5mm/5min
- TBUT <10 sec
- Corneal staining present
Code-Specific Risks
- Ensure laterality is documented to avoid unspecified coding.
Coding Notes
- Document specific test results and laterality to support coding.
H04.122 - Dry eye syndrome of left lacrimal gland
Use when dry eye is confirmed in the left eye with specific clinical findings.
Applicable To
- Tear film insufficiency
- Lacrimal gland dysfunction
Excludes
- Sjögren's syndrome (M35.01)
Clinical Validation Requirements
- Schirmer ≤5mm/5min
- TBUT <10 sec
- Corneal staining present
Coding Notes
Document specific test results and laterality to support coding.
H04.123 - Dry eye syndrome of bilateral lacrimal glands
Use when dry eye is confirmed in both eyes with specific clinical findings.
Applicable To
- Tear film insufficiency
- Lacrimal gland dysfunction
Excludes
- Sjögren's syndrome (M35.01)
Clinical Validation Requirements
- Schirmer ≤5mm/5min
- TBUT <10 sec
- Corneal staining present
Coding Notes
Document specific test results and bilateral involvement to support coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Keratitis due to dry eye, right eye
H16.221Keratitis due to dry eye, left eye
H16.222Keratitis due to dry eye, bilateral
H16.223Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Sjögren's syndrome
M35.01Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dry Eye to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H04.121.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Increases risk of audit and compliance issues., Financial: Potential for denied claims and reduced reimbursement.
Mitigation Strategy
Always specify which eye is affected in the documentation., Use specific codes for right, left, or bilateral involvement.
Impact
Reimbursement: May lead to denied claims or reduced reimbursement., Compliance: Increases risk of audit due to unspecified coding., Data Quality: Reduces accuracy of clinical data and patient records.
Mitigation Strategy
Always document laterality and specific test results to use specific codes.
Impact
Using unspecified codes increases audit risk.
Mitigation Strategy
Document laterality and specific test results to use specific codes.
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, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dry Eye
Use these documentation templates to ensure complete and accurate documentation for Dry Eye. These templates include all required elements for proper coding and billing.
Initial evaluation of dry eye
Specialty: OphthalmologyRequired Elements
- Patient history
- Schirmer's test results
- TBUT results
- Corneal staining findings
- Treatment history
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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