Paralytic lagophthalmos left eye, unspecified eyelid
ICD-10 H02.236 is a billable code used to indicate a diagnosis of paralytic lagophthalmos left eye, unspecified eyelid.
Paralytic lagophthalmos of the left eye, unspecified eyelid, is characterized by the inability to fully close the eyelid due to paralysis of the facial muscles innervated by the facial nerve (cranial nerve VII). This condition can result from various etiologies, including Bell's palsy, stroke, or trauma. The anatomy involved includes the eyelids, which consist of the upper and lower eyelids, and the orbicularis oculi muscle, responsible for eyelid closure. The lacrimal system may also be affected, leading to inadequate tear distribution and potential exposure keratitis. Disease progression can lead to complications such as corneal dryness, irritation, and infection if not properly managed. Diagnostic considerations include a thorough clinical examination, patient history, and possibly imaging studies to assess underlying causes. Treatment may involve protective measures for the eye, such as lubricating eye drops, eyelid weights, or surgical intervention to improve eyelid closure.
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
H02.236 covers paralytic lagophthalmos specifically affecting the left eye, which may arise from conditions like Bell's palsy, stroke, or traumatic facial nerve injury. It is essential to differentiate it from other eyelid disorders such as ptosis or mechanical lagophthalmos.
H02.236 should be used when the patient presents with paralysis affecting the left eyelid specifically, and other causes of eyelid dysfunction have been ruled out. It is crucial to document the clinical findings that support this diagnosis.
Documentation should include a comprehensive eye examination, details of the patient's medical history, neurological assessment findings, and any imaging studies performed. Clear notes on the impact of the condition on the patient's daily life and treatment plan are also necessary.
