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ICD-10 Guide
ICD-10 CodesH11.05

H11.05

Non-billable

Peripheral pterygium of eye, progressive

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

Code Description

ICD-10 H11.05 is a used to indicate a diagnosis of peripheral pterygium of eye, progressive.

Key Diagnostic Point:

Peripheral pterygium of the eye, progressive, is characterized by a triangular-shaped growth of conjunctival tissue that extends onto the cornea, often leading to visual impairment. This condition typically arises due to chronic irritation from environmental factors such as UV exposure, dust, and wind. The anatomy involved includes the conjunctiva, which is the membrane covering the white part of the eye, the sclera, and the cornea. As the pterygium progresses, it can encroach upon the visual axis, potentially causing astigmatism or other refractive errors. Clinically, patients may present with symptoms such as redness, irritation, and a foreign body sensation. Diagnosis is primarily clinical, based on the appearance of the growth during a slit-lamp examination. In some cases, imaging may be utilized to assess the extent of the pterygium. Early intervention is crucial to prevent significant visual impairment, and treatment options may include lubricating eye drops, corticosteroid injections, or surgical excision in more advanced cases.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity
  • Treatment complexity
  • Documentation requirements
  • Coding specificity

Audit Risk Factors

  • Common coding errors include misclassifying the pterygium as non-progressive.
  • Documentation gaps may arise if the progression of symptoms is not clearly noted.
  • Billing challenges can occur if the treatment plan is not adequately supported by clinical evidence.

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 H11.05 lies in its potential to cause visual impairment, impacting patients' quality of life. Population health impact includes increased healthcare utilization for surgical interventions and follow-up care. Quality measures may focus on timely diagnosis and treatment to prevent complications. Epidemiologically, pterygium is more prevalent in populations with high UV exposure, highlighting the need for preventive measures in at-risk groups.

ICD-9 vs ICD-10

The clinical significance of H11.05 lies in its potential to cause visual impairment, impacting patients' quality of life. Population health impact includes increased healthcare utilization for surgical interventions and follow-up care. Quality measures may focus on timely diagnosis and treatment to prevent complications. Epidemiologically, pterygium is more prevalent in populations with high UV exposure, highlighting the need for preventive measures in at-risk groups.

Reimbursement & Billing Impact

Reimbursement considerations include the necessity of surgical intervention if conservative treatments fail. Common denials may arise from insufficient documentation of progression or lack of medical necessity for surgery. Best practices include thorough documentation of symptoms, treatment history, and any imaging studies performed to support the diagnosis and treatment plan.

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 H11.05?

H11.05 specifically covers progressive peripheral pterygium, which is characterized by the growth of conjunctival tissue onto the cornea. It is distinguished from non-progressive forms and other conjunctival lesions.

When should H11.05 be used instead of related codes?

H11.05 should be used when there is clear evidence of progression of the pterygium affecting the cornea. If the pterygium is stable or non-progressive, H11.04 should be utilized instead.

What documentation supports H11.05?

Documentation should include a detailed clinical examination report, noting the size, location, and progression of the pterygium, as well as any symptoms reported by the patient. Treatment plans and follow-up notes are also essential.