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ICD-10 Guide
ICD-10 CodesH02.233

H02.233

Billable

Paralytic lagophthalmos right eye, unspecified eyelid

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 H02.233 is a billable code used to indicate a diagnosis of paralytic lagophthalmos right eye, unspecified eyelid.

Key Diagnostic Point:

Paralytic lagophthalmos refers to the inability to completely close the eyelids due to paralysis of the facial nerve, affecting the right eye and unspecified eyelid. This condition can arise from various etiologies, including Bell's palsy, stroke, or trauma. The eyelid anatomy consists of the upper and lower eyelids, which play a crucial role in protecting the eye, maintaining moisture, and facilitating tear distribution. In cases of lagophthalmos, the exposed cornea is at risk for dryness, irritation, and potential ulceration, leading to complications such as keratitis. Disease progression can vary, with some patients experiencing transient symptoms while others may have chronic exposure issues. Diagnosis typically involves a thorough clinical examination, including assessment of eyelid closure, corneal health, and potential underlying neurological conditions. Additional diagnostic tests may include imaging studies or nerve conduction studies to evaluate the extent of nerve involvement. Treatment options may range from conservative measures, such as lubricating eye drops, to surgical interventions aimed at improving eyelid closure and protecting the cornea.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Requires understanding of neurological conditions and their impact on eyelid function.
  • Treatment complexity: May involve multidisciplinary approaches including ophthalmology and neurology.
  • Documentation requirements: Detailed clinical notes and evidence of nerve impairment are necessary.
  • Coding specificity: Requires precise coding to differentiate from other eyelid disorders.

Audit Risk Factors

  • Common coding errors: Misidentification of the affected eyelid or eye.
  • Documentation gaps: Incomplete clinical notes regarding the extent of paralysis.
  • Billing challenges: Potential denials if the relationship between the condition and treatment is not clearly documented.

Specialty Focus

Medical Specialties

Ophthalmology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Neurology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related ICD-10 Codes

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Paralytic lagophthalmos can significantly impact a patient's quality of life, leading to discomfort and potential vision loss if left untreated. It is essential for healthcare providers to recognize and address this condition promptly to prevent complications. The prevalence of facial nerve disorders contributing to lagophthalmos highlights the need for awareness in both primary care and specialty settings, as early intervention can improve patient outcomes and reduce healthcare utilization related to corneal complications.

ICD-9 vs ICD-10

Paralytic lagophthalmos can significantly impact a patient's quality of life, leading to discomfort and potential vision loss if left untreated. It is essential for healthcare providers to recognize and address this condition promptly to prevent complications. The prevalence of facial nerve disorders contributing to lagophthalmos highlights the need for awareness in both primary care and specialty settings, as early intervention can improve patient outcomes and reduce healthcare utilization related to corneal complications.

Reimbursement & Billing Impact

Reimbursement considerations may vary based on the complexity of the case and the treatments rendered. Common denials can occur if the relationship between the diagnosis and the treatment is not well-supported in the clinical notes. Best practices include thorough documentation of the patient's history, clinical findings, and treatment rationale, as well as ensuring that all relevant CPT codes are accurately reported alongside H02.233.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for H00-H99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for H00-H99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by H02.233?

H02.233 specifically covers paralytic lagophthalmos affecting the right eye and unspecified eyelid, primarily due to facial nerve paralysis. Conditions such as Bell's palsy, post-stroke facial weakness, or trauma-related nerve damage may lead to this diagnosis.

When should H02.233 be used instead of related codes?

H02.233 should be used when there is clear documentation of paralysis affecting the right eye's eyelid closure. It is distinct from other codes that may describe non-paralytic eyelid disorders or lagophthalmos affecting other eyelids.

What documentation supports H02.233?

Documentation should include a detailed clinical examination noting the extent of eyelid closure, any neurological assessments performed, and treatment plans. Evidence of corneal exposure or irritation should also be documented to support the diagnosis.