The TFOS DEWS2 report did a wonderful job of highlighting the many etiologies that underscore ocular surface disease. Most of the doctors I work with have a general grasp of the differences between aqueous deficiency and evaporative disease and the large blending between them. The challenge I see many doctors and students encountering is that they get stuck on the idea that when coding for a patient with ocular surface disease, every patient is coded with the ICD-10 code H04.123, or dry eye syndrome of bilateral lacrimal glands.
This custom is not incorrect; however, there are reasons to utilize more specific ICD-10 codes when billing and coding when these additional codes are clinically relevant. In this article, I will discuss the plethora of dry eye ICD-10 codes and why it is important to consider including additional specificity in your clinical notes.
Let’s review the 40 most relevant ICD-10 codes for patients with ocular surface disease and dry eye
Besides my clinical experience, I wanted to break down this list in descending order based on a few rules.
- It is important to think about the list in terms of more common to less common, so I will present more common conditions before less common conditions.
- I will attempt to start with more general conditions and progress to more specific diagnosis.
- To be complete, I will include both unilateral and bilateral codes in the list.
|Dry eye syndrome of bilateral lacrimal glands||H04.123|
|Dry eye syndrome of right lacrimal gland||H04.121|
|Dry eye syndrome of left lacrimal gland||H04.122|
|Meibomian gland dysfunction right eye, upper and lower eyelids||H02.88A|
|Meibomian gland dysfunction left eye, upper and lower eyelids||H02.88B|
|Punctate Keratitis, bilateral||H16.143|
|Punctate Keratitis, right eye||H16.141|
|Punctate Keratitis, left eye||H16.142|
|Superficial Keratitis, unspecified, bilateral||H16.103|
|Superficial Keratitis, unspecified, right eye||H16.101|
|Superficial Keratitis, unspecified, left eye||H16.102|
|Epiphora, bilateral lacrimal gland||H04.203|
|Epiphora, right lacrimal gland||H04.201|
|Epiphora, left lacrimal gland||H04.202|
|Ocular pain, bilateral||H57.13|
|Ocular pain, right eye||H57.11|
|Ocular pain, left eye||H57.12|
|Keratoconjunctivitis sicca, non-Sjögren's syndrome, bilateral||H16.223|
|Keratoconjunctivitis sicca, non-Sjögren's syndrome, right eye||H16.221|
|Keratoconjunctivitis sicca, non-Sjögren's syndrome, left eye||H16.222|
|Recurrent Erosion of Cornea, bilateral||H18.833|
|Recurrent Erosion of Cornea, right eye||H18.831|
|Recurrent Erosion of Cornea, left eye||H18.832|
|Nodular corneal degeneration, bilateral||H18.453|
|Nodular corneal degeneration, right eye||H18.451|
|Nodular corneal degeneration, left eye||H18.452|
|Filamentary Keratitis, bilateral||H16.123|
|Filamentary Keratitis, right eye||H16.121|
|Filamentary Keratitis, left eye||H16.122|
|Exposure Keratoconjunctivitis, bilateral||H16.213|
|Exposure Keratoconjunctivitis, right eye||H16.211|
|Exposure Keratoconjunctivitis, left eye||H16.212|
|Neurotrophic keratoconjunctivitis, bilateral||H16.233|
|Neurotrophic keratoconjunctivitis, right eye||H16.231|
|Neurotrophic keratoconjunctivitis, left eye||H16.232|
|Anterior basement membrane dystrophy, bilateral||H18.593|
|Anterior basement membrane dystrophy, right eye||H18.591|
|Anterior basement membrane dystrophy, left eye||H18.592|
|Sicca syndrome (Sjögren) with keratoconjunctivitis||M35.01|
|Sicca syndrome (Sjögren), unspecified||M35.00|
Including relevant codes absolutely matters for medical decision-making (MDM) in determining the appropriate evaluation and management code
It is beyond the scope of this article to go into all of the nuances of the AMA 2021 changes to the guidelines for evaluation and management codes, but we will utilize the above AMA document to understand how we would classify different problems below. There are additional resources to help you walk through the fine details. For the purposes of this article, we will discuss how the number of problems that are managed will impact your overall MDM level and thus your 992XX code choice.
When I consult with doctors about their dry eye management in their practice, I have noticed that it is customary to find one ICD-10 diagnosis code and only document that code in the assessment. When I ask why they only use one code it is commonly because the doctor understands that only one code is all that is necessary to be reimbursed for a service. They are not incorrect, but it will almost certainly limit their code level.
It is also important to remember that the type of problem and the number of problems addressed will impact your MDM. So documenting and billing more than one problem when it is being managed during a particular encounter is very important.
First, consider what the AMA defines as a “problem”
The AMA defines a problem as “a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.”
What this means is that a patient who complains of scratchy and gritty eyes that may have the general condition we call dry eye syndrome (H04.123) also has clinical findings/conditions that you are addressing and attending to such as superficial punctate keratitis (H16.103) and meibomian gland dysfunction (H02.88A(B)). Let’s also say that based on the prior history and examination we note that signs and symptoms in this patient are stable.
Second, consider what the AMA defines as a “stable chronic illness”
The AMA defines a stable, chronic illness as “A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). “Stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient.”
We can see that these are conditions (at least dry eye and meibomian gland dysfunction) that are likely to be present for more than 1 year in duration so we can classify them as chronic.
Third, consider what problem level the AMA assigns to managing two or more stable chronic illnesses within MDM
The AMA provides in their guidance that addressing 2 or more stable chronic illnesses is a moderate number of problems addressed. So thinking in terms of 99 code level, this would allow for a 992X4 code if you also did one of the following:
- Ordered or analyzed 3 additional tests
- Communicated with an external physician about the case
- Independently interpreted tests performed by another physician
- Prescribed a prescription medication
- Decided on major surgery
- Decided on minor surgery in a patient with additional risk factors
Alternatively, if you only listed the diagnosis of H04.123, you would be limited to a 992X3 unless you also performed any one of the following; ordered or analyzed 3 additional tests, communicated with an external physician about the case, independently interpreted tests performed by another physician AND any one of the following; Prescribed a prescription medication, decided on major surgery, decided on minor surgery in a patient with additional risk factors.
Choosing the appropriate dry eye ICD-10 codes helps articulate the complexity of the case and also justifies the coding level
First and foremost, it is important to note that we include all of the problems that we are addressing in our assessment and plan so that we provide the most accurate picture of our encounter with a specific patient. In doing so it provides us with a clear path to justify past decisions and make future decisions.
Second, by including all of the problems addressed during a specific encounter we can code our encounters more appropriately based on our specific documentation for a specific patient. When we understand the nuances of the 992XX codes will allow us to fully describe the level of care we provided for a patient in a way that will protect against audits and likely improve reimbursements.
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