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v1.0.0
ICD-10 Guide
ICD-10 CodesH11.0

H11.0

Non-billable

Pterygium of eye

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

Code Description

ICD-10 H11.0 is a used to indicate a diagnosis of pterygium of eye.

Key Diagnostic Point:

Pterygium is a benign growth of conjunctival tissue that extends onto the cornea, often characterized by a triangular shape. It typically arises from the nasal side of the eye and can cause discomfort, redness, and visual disturbances as it progresses. The growth is associated with environmental factors such as UV exposure, wind, and dust, making it more prevalent in individuals who spend significant time outdoors. Anatomically, pterygium affects the conjunctiva, sclera, and cornea, potentially leading to astigmatism or other refractive errors if it encroaches upon the visual axis. Diagnosis is primarily clinical, based on the appearance of the growth and patient symptoms. In some cases, imaging studies may be used to assess the extent of the lesion. Treatment options range from observation for asymptomatic cases to surgical excision for those causing significant symptoms or visual impairment. Recurrence after surgery is common, necessitating careful monitoring and follow-up.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Moderate, as diagnosis is primarily clinical but may require differentiation from other conjunctival lesions.
  • Treatment complexity: Moderate, with options ranging from conservative management to surgical intervention.
  • Documentation requirements: Requires thorough documentation of symptoms, examination findings, and treatment plans.
  • Coding specificity: Specific to pterygium, but may require additional codes for associated conditions.

Audit Risk Factors

  • Common coding errors: Misclassification of pterygium as a malignant lesion.
  • Documentation gaps: Incomplete records of symptoms or treatment rationale.
  • Billing challenges: Potential denials for surgical procedures if documentation does not support medical necessity.

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

Primary Care

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

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Pterygium is a common condition, particularly in populations with high UV exposure, impacting visual health and quality of life. Its prevalence can lead to increased healthcare utilization, including surgical interventions. Understanding the epidemiology of pterygium can inform public health initiatives aimed at reducing risk factors, such as UV protection. Quality measures may include tracking surgical outcomes and recurrence rates, which are critical for improving patient care.

ICD-9 vs ICD-10

Pterygium is a common condition, particularly in populations with high UV exposure, impacting visual health and quality of life. Its prevalence can lead to increased healthcare utilization, including surgical interventions. Understanding the epidemiology of pterygium can inform public health initiatives aimed at reducing risk factors, such as UV protection. Quality measures may include tracking surgical outcomes and recurrence rates, which are critical for improving patient care.

Reimbursement & Billing Impact

impact on vision and quality of life. Ensure that all relevant codes are included, such as the appropriate CPT codes for excision. Common denials may arise from insufficient documentation or lack of evidence supporting the need for surgery. Best practices include maintaining clear records of patient symptoms, treatment discussions, and follow-up care to support claims and reduce audit risks.

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 H11.0?

H11.0 specifically covers pterygium, a growth of conjunctival tissue on the cornea. It does not include other conjunctival or corneal disorders such as conjunctivitis or corneal ulcers.

When should H11.0 be used instead of related codes?

H11.0 should be used when the diagnosis is specifically pterygium without laterality. If laterality is known, H11.1 or H11.2 should be used instead.

What documentation supports H11.0?

Documentation should include a detailed description of the growth, patient symptoms, visual acuity measurements, and any treatment plans or interventions undertaken.