ICD-10 Coding for Bilateral Dry Eye Syndrome(H04.123, H04.13)
Complete ICD-10-CM coding and documentation guide for Bilateral Dry Eye Syndrome. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Dry Eye Syndrome
H04.12-H04.13Primary Range
Disorders of lacrimal gland
This range includes codes for dry eye syndrome with specific focus on lacrimal gland involvement and general bilateral cases.
Sjögren's syndrome
Relevant for cases where dry eye syndrome is associated with Sjögren's syndrome.
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 when documentation explicitly links dryness to bilateral lacrimal gland dysfunction. |
|
| H04.13 | Bilateral dry eye syndrome, not specified as Sjögren's | Use for general bilateral dry eye cases without specific lacrimal gland involvement. |
|
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 syndrome
Essential facts and insights about Bilateral Dry Eye Syndrome
Primary ICD-10-CM Codes for dry eye syndrome bilateral
Decision Criteria
clinical Criteria
- Schirmer’s test <10mm and TBUT <10 seconds
documentation Criteria
- Explicit mention of bilateral lacrimal gland involvement
Applicable To
- Bilateral lacrimal gland dysfunction
Excludes
- Sjögren's syndrome (M35.0)
Clinical Validation Requirements
- Schirmer’s test <10mm
- TBUT <10 seconds
- Corneal staining
Code-Specific Risks
- Misclassification if lacrimal gland involvement is not documented.
Coding Notes
- Ensure documentation specifies bilateral involvement and lacrimal gland dysfunction.
H04.13 - Bilateral dry eye syndrome, not specified as Sjögren's
Use for general bilateral dry eye cases without specific lacrimal gland involvement.
Applicable To
- General bilateral dry eye
Excludes
- Sjögren's syndrome (M35.0)
Clinical Validation Requirements
- Patient-reported symptoms
- Clinical examination confirming bilateral dry eye
Coding Notes
Ensure laterality is documented as bilateral.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Eye Syndrome 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 assessment of condition severity., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure all relevant tests are documented., Use templates to guide documentation.
Impact
Reimbursement: Potential denials due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data.
Mitigation Strategy
Always document and code for bilateral involvement if confirmed.
Impact
Risk of audits due to use of unspecified codes.
Mitigation Strategy
Ensure documentation supports the use of 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 Bilateral Dry Eye Syndrome, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Dry Eye Syndrome
Use these documentation templates to ensure complete and accurate documentation for Bilateral Dry Eye Syndrome. These templates include all required elements for proper coding and billing.
Ophthalmology Progress Note
Specialty: OphthalmologyRequired Elements
- Chief complaint
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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