Unspecified lagophthalmos left upper eyelid
ICD-10 H02.204 is a billable code used to indicate a diagnosis of unspecified lagophthalmos left upper eyelid.
Lagophthalmos is a condition characterized by the inability to fully close the eyelids, which can lead to exposure of the cornea and subsequent complications such as dryness, irritation, and potential corneal ulceration. In the case of unspecified lagophthalmos of the left upper eyelid, the patient may present with symptoms including excessive tearing, discomfort, and visual disturbances. The anatomy involved includes the eyelids, particularly the orbicularis oculi muscle, which is responsible for eyelid closure, and the surrounding periocular structures. Disease progression can vary, with acute cases often resulting from trauma or neurological conditions, while chronic cases may be associated with conditions such as Bell's palsy or thyroid eye disease. Diagnostic considerations include a thorough clinical examination, assessment of eyelid function, and possibly imaging studies to evaluate underlying causes. Treatment options may range from lubricating eye drops to surgical interventions, depending on the severity and underlying etiology of the lagophthalmos.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
H02.204 covers unspecified lagophthalmos of the left upper eyelid, which may arise from various conditions such as facial nerve paralysis, trauma, or congenital anomalies. It is important to document the underlying cause if known.
H02.204 should be used when the lagophthalmos is specifically affecting the left upper eyelid and the cause is not specified. If the cause is known, a more specific code may be appropriate.
Documentation should include a detailed history of the patient's symptoms, clinical examination findings, any diagnostic tests performed, and the treatment plan. Notes should clearly indicate the affected eyelid and any relevant underlying conditions.
