ICD-10 Coding for Dermatochalasis(H02.831, H02.834, H02.839)
Complete ICD-10-CM coding and documentation guide for Dermatochalasis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dermatochalasis
H02.83-Primary Range
Dermatochalasis
This range covers the specific codes for dermatochalasis, including laterality and specific eyelid involvement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H02.831 | Dermatochalasis of right upper eyelid | Use when dermatochalasis affects the right upper eyelid with documented visual impairment. |
|
| H02.834 | Dermatochalasis of left upper eyelid | Use when dermatochalasis affects the left upper eyelid with documented visual impairment. |
|
| H02.839 | Dermatochalasis, unspecified eyelid | Use when specific laterality is not documented. |
|
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 dermatochalasis
Essential facts and insights about Dermatochalasis
Primary ICD-10-CM Codes for dermatochalasis
Decision Criteria
clinical Criteria
- Presence of redundant skin causing visual impairment
documentation Criteria
- Photographic evidence and visual field testing
Applicable To
- Redundant skin of right upper eyelid
Excludes
- Congenital eyelid malformations (Q10.-)
Clinical Validation Requirements
- Visual field loss of ≥30% or 12°
- Photographic evidence of eyelid redundancy
Code-Specific Risks
- Incorrect laterality documentation
- Missing visual field test results
Coding Notes
- Ensure documentation specifies laterality and includes visual field test results.
H02.834 - Dermatochalasis of left upper eyelid
Use when dermatochalasis affects the left upper eyelid with documented visual impairment.
Applicable To
- Redundant skin of left upper eyelid
Excludes
- Congenital eyelid malformations (Q10.-)
Clinical Validation Requirements
- Visual field loss of ≥30% or 12°
- Photographic evidence of eyelid redundancy
Coding Notes
Ensure documentation specifies laterality and includes visual field test results.
H02.839 - Dermatochalasis, unspecified eyelid
Use when specific laterality is not documented.
Applicable To
- Redundant skin of unspecified eyelid
Excludes
- Congenital eyelid malformations (Q10.-)
Clinical Validation Requirements
- General documentation of eyelid redundancy
Coding Notes
Use only when laterality cannot be determined.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for surgical aftercare following surgery on the eye and adnexa
Z48.81Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Mechanical ptosis
H02.41-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dermatochalasis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H02.831.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of audit and non-compliance., Financial: Potential for claim denials.
Mitigation Strategy
Ensure visual field tests are conducted and results documented., Include photographic evidence in patient records.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Increases risk of audit and non-compliance., Data Quality: Affects accuracy of patient records and data reporting.
Mitigation Strategy
Ensure documentation specifies laterality and use the corresponding specific code.
Impact
Using unspecified codes when laterality is documented.
Mitigation Strategy
Ensure documentation specifies laterality and use the corresponding specific code.
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 Dermatochalasis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dermatochalasis
Use these documentation templates to ensure complete and accurate documentation for Dermatochalasis. These templates include all required elements for proper coding and billing.
Ophthalmology evaluation for dermatochalasis
Specialty: OphthalmologyRequired Elements
- Patient symptoms
- Visual field test results
- Photographic evidence
- Eyelid measurements
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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