ICD-10 Coding for Dry Eye Syndrome(H04.121, H04.122, H04.123, H16.22-, M35.0)
Complete ICD-10-CM coding and documentation guide for 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 Dry Eye Syndrome
H04.121-H04.123Primary Range
Dry eye syndrome with specified lacrimal gland involvement
Primary range for coding dry eye syndrome based on lacrimal gland involvement.
Keratoconjunctivitis sicca (KCS)
Used when corneal staining is present, indicating keratoconjunctivitis sicca.
Sjögren's syndrome
Primary if dry eye is due to autoimmune etiology confirmed by specific tests.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H04.121 | Dry eye syndrome, right lacrimal gland | Use when dry eye is confirmed with specific tests for the right eye. |
|
| H04.122 | Dry eye syndrome, left lacrimal gland | Use when dry eye is confirmed with specific tests for the left eye. |
|
| H04.123 | Dry eye syndrome, bilateral lacrimal glands | Use when dry eye is confirmed with specific tests for both eyes. |
|
| H16.22- | Keratoconjunctivitis sicca, not specified as Sjögren's | Use when corneal staining is present, indicating keratoconjunctivitis sicca. |
|
| M35.0 | Sjögren's syndrome | Primary if dry eye is due to autoimmune etiology confirmed by specific tests. |
|
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 eye syndrome
Essential facts and insights about Dry Eye Syndrome
Primary ICD-10-CM Codes for dry eye syndrome
Decision Criteria
clinical Criteria
- Schirmer test ≤5 mm in the right eye
Applicable To
- Aqueous tear deficiency
Excludes
- Keratoconjunctivitis sicca (H16.22-)
Clinical Validation Requirements
- Schirmer test ≤5 mm
- Tear osmolarity >308 mOsm/L
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented to avoid unspecified codes.
H04.122 - Dry eye syndrome, left lacrimal gland
Use when dry eye is confirmed with specific tests for the left eye.
Applicable To
- Aqueous tear deficiency
Excludes
- Keratoconjunctivitis sicca (H16.22-)
Clinical Validation Requirements
- Schirmer test ≤5 mm
- Tear osmolarity >308 mOsm/L
Coding Notes
Ensure laterality is documented to avoid unspecified codes.
H04.123 - Dry eye syndrome, bilateral lacrimal glands
Use when dry eye is confirmed with specific tests for both eyes.
Applicable To
- Aqueous tear deficiency
Excludes
- Keratoconjunctivitis sicca (H16.22-)
Clinical Validation Requirements
- Schirmer test ≤5 mm
- Tear osmolarity >308 mOsm/L
Coding Notes
Ensure laterality is documented to avoid unspecified codes.
H16.22- - Keratoconjunctivitis sicca, not specified as Sjögren's
Use when corneal staining is present, indicating keratoconjunctivitis sicca.
Applicable To
- Dry eye syndrome with corneal involvement
Excludes
- Sjögren's syndrome (M35.0)
Clinical Validation Requirements
- Corneal staining
- TBUT <7 seconds
Coding Notes
Ensure corneal involvement is documented.
M35.0 - Sjögren's syndrome
Primary if dry eye is due to autoimmune etiology confirmed by specific tests.
Applicable To
- Dry eye syndrome due to autoimmune etiology
Excludes
- Keratoconjunctivitis sicca (H16.22-)
Clinical Validation Requirements
- Positive SSA/SSB antibodies
- Salivary gland biopsy
Coding Notes
Ensure autoimmune etiology is confirmed before coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Conjunctival vascularization
H11.4-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dry Eye Syndrome 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 clinical records., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always document laterality in the patient record., Use specific codes for right, left, or bilateral involvement.
Impact
Reimbursement: May lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Ensure laterality is documented and use specific codes like H04.121-H04.123.
Impact
Reimbursement: Incorrect coding may affect reimbursement rates., Compliance: Potential audit issues., Data Quality: Impacts clinical data integrity.
Mitigation Strategy
Differentiate based on clinical findings such as corneal staining.
Impact
High risk of audit when unspecified codes are used without justification.
Mitigation Strategy
Document specific laterality and test results to justify code selection.
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 Eye Syndrome, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dry Eye Syndrome
Use these documentation templates to ensure complete and accurate documentation for Dry Eye Syndrome. These templates include all required elements for proper coding and billing.
Ophthalmology Progress Note
Specialty: OphthalmologyRequired Elements
- Subjective symptoms
- Objective findings
- Test results
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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