Back to HomeBeta

ICD-10 Coding for Dry Eyes(H04.121, H04.122, H04.123)

Complete ICD-10-CM coding and documentation guide for Dry Eyes. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Dry Eye SyndromeKeratoconjunctivitis SiccaTear Film Insufficiency

Quick Navigation

Related ICD-10 Code Ranges

Complete code families applicable to Dry Eyes

H04.12-Primary Range

Dry eye syndrome affecting the lacrimal glands

Primary range for coding dry eye syndrome related to lacrimal gland dysfunction.

H16.22-

Keratoconjunctivitis sicca not specified as Sjögren's

Used for inflammatory dry eye conditions not related to Sjögren's syndrome.

M35.00

Sicca syndrome

Used when systemic autoimmune involvement is present.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
H04.121Dry eye syndrome, right lacrimal glandUse when dry eye symptoms are confirmed with objective tests for the right eye.
  • Schirmer test ≤5mm/5min
  • Tear osmolarity >316 mOsm/L
H04.122Dry eye syndrome, left lacrimal glandUse when dry eye symptoms are confirmed with objective tests for the left eye.
  • Schirmer test ≤5mm/5min
  • Tear osmolarity >316 mOsm/L
H04.123Dry eye syndrome, bilateral lacrimal glandsUse when dry eye symptoms are confirmed with objective tests for both eyes.
  • Schirmer test ≤5mm/5min
  • Tear osmolarity >316 mOsm/L

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 eyes

Essential facts and insights about Dry Eyes

The ICD-10 code for dry eyes is H04.12-, specifying dry eye syndrome related to lacrimal gland dysfunction. Document laterality for precision.

Primary ICD-10-CM Codes for dry eyes

H04.121
Dry eye syndrome, right lacrimal gland
Billable Code

Decision Criteria

clinical Criteria

  • Objective test results confirming dry eye in the right eye.

Applicable To

  • Tear film insufficiency, right eye

Excludes

Clinical Validation Requirements

  • Schirmer test ≤5mm/5min
  • Tear osmolarity >316 mOsm/L

Code-Specific Risks

  • Risk of using unspecified codes when laterality is documented.

Coding Notes

  • Ensure laterality is documented to avoid unspecified codes.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Eye pain

R07.9
Use to report symptoms when eye pain is present without confirmed etiology.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Keratoconjunctivitis sicca, not specified as Sjögren's, right eye

H16.221
Use when inflammation is the primary concern rather than tear deficiency.

Keratoconjunctivitis sicca, not specified as Sjögren's, left eye

H16.222
Use when inflammation is the primary concern rather than tear deficiency.

Keratoconjunctivitis sicca, not specified as Sjögren's, bilateral

H16.223
Use when inflammation is the primary concern rather than tear deficiency.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Dry Eyes to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H04.121.

Impact

Clinical: Inaccurate treatment plans due to lack of specificity., Regulatory: Potential for audit issues due to non-compliance., Financial: Claims may be denied due to unspecified coding.

Mitigation Strategy

Always specify laterality in documentation., Use templates that prompt for laterality.

Impact

Reimbursement: Unspecified codes can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data.

Mitigation Strategy

Ensure laterality is specified and use H04.121, H04.122, or H04.123 as appropriate.

Impact

High risk of audit when unspecified codes are used without justification.

Mitigation Strategy

Ensure documentation supports the most specific code available.

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 Eyes, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Dry Eyes

Use these documentation templates to ensure complete and accurate documentation for Dry Eyes. These templates include all required elements for proper coding and billing.

Ophthalmology Progress Note

Specialty: Ophthalmology

Required Elements

  • Subjective symptoms
  • Objective test results
  • Assessment and plan

Example Documentation

**Subjective:** "Burning OD > OS, worse with screen use. Failed OTC tears x4 weeks." **Objective:** - Schirmer: 2mm OD / 3mm OS - Tear osmolarity: 335 mOsm/L OD, 330 mOsm/L OS - Lissamine green: Grade 3 staining OD, Grade 2 OS **Assessment:** H04.121 (DES right lacrimal gland), H04.122 (DES left lacrimal gland) **Plan:** Punctal plugs OD/OS (68761), cyclosporine 0.05% BID

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient complains of dry eyes. Tear production appears low.
Good Documentation Example
Severe dry eye syndrome bilateral lacrimal glands (Schirmer: 3mm OD/4mm OS; tear osmolarity 328 mOsm/L OU). Grade 3 corneal staining OD/OS.
Explanation
The good example provides specific test results and laterality, which are necessary for accurate coding.

Need help with ICD-10 coding for Dry Eyes? Ask your questions below.

Ask about any ICD-10 CM code, or paste a medical note

We build tools for
clinician happiness.

Learn More at Freed.ai
Back to HomeBeta

Built by Freed

Try Freed for free for 7 days.

Learn more

Helpful Links

How ICD 10 AI Lookup WorksContact UsPrivacy Policy