ICD-10 Coding for Chronic Tearing of the Right Eye(H04.201)
Complete ICD-10-CM coding and documentation guide for Chronic Tearing of the Right Eye. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Chronic Tearing of the Right Eye
H04.2-H04.3Primary Range
Disorders of lacrimal system
This range includes codes for epiphora and other lacrimal system disorders, which are directly relevant to chronic tearing.
Key Information: ICD-10 code for chronic tearing of the right eye
Essential facts and insights about Chronic Tearing of the Right Eye
Primary ICD-10-CM Code for chronic tearing of the right eye
Decision Criteria
clinical Criteria
- Presence of chronic tearing with no identifiable obstruction.
documentation Criteria
- Documentation must specify 'right lacrimal system' and objective test results.
Applicable To
- Chronic tearing of the right eye
Excludes
- Dry eye syndrome (H04.121)
Clinical Validation Requirements
- Schirmer test ≤10mm/5min
- Jones test negative
- Objective findings of tear overflow
Code-Specific Risks
- Risk of using unspecified codes like H04.209 when laterality is documented.
Coding Notes
- Ensure documentation specifies 'chronic' and 'right side' to avoid unspecified codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Epiphora due to insufficient drainage, right
H04.221Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Dry eye syndrome, right lacrimal gland
H04.121Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Chronic Tearing of the Right Eye to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H04.201.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with coding specificity requirements., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Ensure thorough history taking and documentation of findings., Use templates to guide comprehensive documentation.
Impact
Reimbursement: May lead to denied claims due to lack of specificity., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Audit for consistent use of 'right' in all note sections.
Impact
Risk of using unspecified codes due to missing laterality information.
Mitigation Strategy
Implement mandatory fields for laterality in electronic health records.
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 Chronic Tearing of the Right Eye, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Chronic Tearing of the Right Eye
Use these documentation templates to ensure complete and accurate documentation for Chronic Tearing of the Right Eye. These templates include all required elements for proper coding and billing.
Chronic tearing due to punctal stenosis
Specialty: OphthalmologyRequired Elements
- Patient history of tearing
- Objective test results
- Findings on physical exam
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Chronic Tearing of the Right Eye? Ask your questions below.