ICD-10 Coding for Bilateral Dry Eyes(H04.123, H04.13B, M35.01)
Complete ICD-10-CM coding and documentation guide for Bilateral Dry Eyes. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Dry Eyes
H04.12-H04.13Primary Range
Disorders of lacrimal gland
This range includes codes for dry eye syndrome, specifying laterality and severity.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H04.123 | Dry eye syndrome of bilateral lacrimal glands | Use for bilateral dry eye syndrome without Sjögren’s syndrome. |
|
| H04.13B | Bilateral dry eye syndrome, moderate severity | Use for moderate severity bilateral dry eye syndrome. |
|
| M35.01 | Sjögren’s syndrome with keratoconjunctivitis | Use when Sjögren’s syndrome is confirmed. |
|
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 eyes
Essential facts and insights about Bilateral Dry Eyes
Primary ICD-10-CM Codes for dry eyes bilateral
Decision Criteria
clinical Criteria
- Presence of bilateral symptoms and exclusion of Sjögren’s syndrome.
Applicable To
- Bilateral dry eye syndrome not specified as Sjögren's
Excludes
- Sjögren's syndrome with keratoconjunctivitis (M35.01)
Clinical Validation Requirements
- Schirmer’s test ≤5mm/5min
- TBUT ≤5 seconds
- Tear osmolarity >308 mOsm/L
Code-Specific Risks
- Ensure laterality is documented to avoid unspecified coding.
Coding Notes
- Avoid using unspecified codes like H04.129.
H04.13B - Bilateral dry eye syndrome, moderate severity
Use for moderate severity bilateral dry eye syndrome.
Applicable To
- Moderate bilateral dry eye syndrome
Excludes
- Severe bilateral dry eye syndrome (H04.13C)
Clinical Validation Requirements
- Corneal staining patterns
- TBUT ≤5 seconds
Coding Notes
Document severity to differentiate from mild or severe cases.
M35.01 - Sjögren’s syndrome with keratoconjunctivitis
Use when Sjögren’s syndrome is confirmed.
Applicable To
- Sjögren’s syndrome with dry eye symptoms
Excludes
- Non-Sjögren’s dry eye syndrome (H04.123)
Clinical Validation Requirements
- Positive SS-A/SS-B antibodies
- Lip biopsy results
Coding Notes
Requires rheumatologic documentation for confirmation.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Punctate keratitis
H16.223Differential 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 Bilateral Dry Eyes to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H04.123.
Impact
Clinical: Inaccurate representation of patient's condition., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient detail.
Mitigation Strategy
Include specific test results like TBUT and Schirmer’s test in documentation.
Impact
Reimbursement: May lead to denied claims due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Always document laterality explicitly.
Impact
Failure to document laterality can lead to audit issues.
Mitigation Strategy
Ensure all documentation specifies 'bilateral' or 'unilateral' as appropriate.
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 Bilateral Dry Eyes, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Dry Eyes
Use these documentation templates to ensure complete and accurate documentation for Bilateral Dry Eyes. These templates include all required elements for proper coding and billing.
Bilateral dry eye syndrome with moderate severity
Specialty: OphthalmologyRequired Elements
- Symptoms
- TBUT
- Corneal staining
- Meibomian gland expression
- Schirmer’s test
- Tear osmolarity
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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