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ICD-10 Guide
ICD-10 CodesH11.042

H11.042

Billable

Peripheral pterygium, stationary, left eye

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

Code Description

ICD-10 H11.042 is a billable code used to indicate a diagnosis of peripheral pterygium, stationary, left eye.

Key Diagnostic Point:

Peripheral pterygium is a benign growth of conjunctival tissue that extends onto the cornea, typically originating from the nasal or temporal conjunctiva. In the case of H11.042, the pterygium is stationary, indicating that it has not progressed in size or severity. Clinically, patients may present with symptoms such as irritation, redness, or a foreign body sensation in the affected eye. The anatomy involved includes the conjunctiva, which is the mucous membrane covering the white part of the eye, the sclera, and the cornea. Disease progression can vary; while some pterygia remain stable, others may grow and potentially affect vision by inducing astigmatism or obstructing the visual axis. Diagnostic considerations include a thorough eye examination, where the growth's appearance, location, and any associated symptoms are assessed. Differential diagnoses may include other conjunctival lesions such as conjunctival cysts or neoplasms. Proper identification and documentation of the condition are crucial for appropriate management and coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Moderate, as distinguishing pterygium from other conjunctival lesions may require clinical expertise.
  • Treatment complexity: Low to medium, depending on whether observation or surgical intervention is needed.
  • Documentation requirements: Moderate, necessitating detailed descriptions of the lesion and symptoms.
  • Coding specificity: High, as H11.042 specifically denotes a stationary peripheral pterygium in the left eye.

Audit Risk Factors

  • Common coding errors: Misidentifying the eye affected or confusing with other conjunctival conditions.
  • Documentation gaps: Incomplete descriptions of symptoms or lesion characteristics.
  • Billing challenges: Potential denials if the condition is not clearly documented as stationary.

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

Optometry

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

The clinical significance of H11.042 lies in its potential to affect visual acuity and patient comfort. While peripheral pterygium is often benign, its presence can lead to complications such as astigmatism or cosmetic concerns. Understanding the epidemiology of pterygium, which is more prevalent in individuals with prolonged sun exposure, can inform public health initiatives aimed at prevention. Quality measures may include monitoring patient outcomes post-treatment and ensuring appropriate follow-up care to mitigate any adverse effects on vision.

ICD-9 vs ICD-10

The clinical significance of H11.042 lies in its potential to affect visual acuity and patient comfort. While peripheral pterygium is often benign, its presence can lead to complications such as astigmatism or cosmetic concerns. Understanding the epidemiology of pterygium, which is more prevalent in individuals with prolonged sun exposure, can inform public health initiatives aimed at prevention. Quality measures may include monitoring patient outcomes post-treatment and ensuring appropriate follow-up care to mitigate any adverse effects on vision.

Reimbursement & Billing Impact

Reimbursement considerations may vary based on the payer, but generally, proper coding and documentation can facilitate claims processing. Common denials may arise from insufficient documentation or misclassification of the condition. Best practices include ensuring that the medical record reflects the diagnosis accurately and includes any relevant treatment plans or follow-up care.

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 H11.042?

H11.042 specifically covers stationary peripheral pterygium in the left eye. It does not include other types of pterygia or conjunctival lesions.

When should H11.042 be used instead of related codes?

H11.042 should be used when the pterygium is confirmed as stationary and located in the left eye. If the pterygium is in the right eye or bilateral, corresponding codes H11.041 or H11.043 should be used.

What documentation supports H11.042?

Documentation should include a detailed clinical examination report describing the pterygium's size, location, and any associated symptoms. Photographic evidence may also support the diagnosis.