ICD-10 Coding for Eye Dryness(H04.121, H04.122, H04.123)
Complete ICD-10-CM coding and documentation guide for Eye Dryness. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Eye Dryness
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 of right lacrimal gland | Use when dry eye is confirmed in the right eye with specific test results |
|
| H04.122 | Dry eye syndrome of left lacrimal gland | Use when dry eye is confirmed in the left eye with specific test results |
|
| H04.123 | Dry eye syndrome of bilateral lacrimal glands | Use when dry eye is confirmed in both eyes with specific test results |
|
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 Eye Dryness
Primary ICD-10-CM Codes for eye dryness
Decision Criteria
clinical Criteria
- Confirmed dry eye in the right eye with Schirmer's test
Applicable To
- Right eye dryness
Excludes
- Keratoconjunctivitis sicca (H16.22x)
Clinical Validation Requirements
- Schirmer's test ≤5mm/5min
- Positive fluorescein staining
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented to avoid unspecified codes
H04.122 - Dry eye syndrome of left lacrimal gland
Use when dry eye is confirmed in the left eye with specific test results
Applicable To
- Left eye dryness
Excludes
- Keratoconjunctivitis sicca (H16.22x)
Clinical Validation Requirements
- Schirmer's test ≤5mm/5min
- Positive fluorescein staining
Coding Notes
Ensure laterality is documented to avoid unspecified codes
H04.123 - Dry eye syndrome of bilateral lacrimal glands
Use when dry eye is confirmed in both eyes with specific test results
Applicable To
- Bilateral eye dryness
Excludes
- Keratoconjunctivitis sicca (H16.22x)
Clinical Validation Requirements
- Schirmer's test ≤5mm/5min
- Positive fluorescein staining
Coding Notes
Ensure laterality is documented to avoid unspecified codes
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 Eye Dryness 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 patient records, Regulatory: Non-compliance with coding guidelines, Financial: Potential claim denials
Mitigation Strategy
Always specify right, left, or bilateral in documentation
Impact
Reimbursement: May lead to claim denials or reduced reimbursement, Compliance: Non-compliance with coding specificity requirements, Data Quality: Decreases accuracy of patient records
Mitigation Strategy
Document laterality and use specific codes like H04.121, H04.122, or H04.123
Impact
High frequency of unspecified codes can trigger audits
Mitigation Strategy
Ensure documentation supports specific laterality coding
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 Eye Dryness, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Eye Dryness
Use these documentation templates to ensure complete and accurate documentation for Eye Dryness. These templates include all required elements for proper coding and billing.
Bilateral dry eye syndrome with Meibomian gland dysfunction
Specialty: OphthalmologyRequired Elements
- Chief complaint
- Examination findings
- Diagnostic tests
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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