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ICD-10 Guide
ICD-10 CodesH11.42

H11.42

Non-billable

Conjunctival edema

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

Code Description

ICD-10 H11.42 is a used to indicate a diagnosis of conjunctival edema.

Key Diagnostic Point:

Conjunctival edema, classified under H11.42, refers to the swelling of the conjunctiva, the thin, transparent membrane that covers the white part of the eye and the inner surface of the eyelids. This condition can arise from various etiologies, including allergic reactions, infections, trauma, or systemic diseases such as angioedema. Clinically, patients may present with symptoms such as redness, discomfort, tearing, and visual disturbances. The anatomy involved includes the conjunctiva, which plays a crucial role in protecting the eye and maintaining moisture. Disease progression can vary; acute conjunctival edema may resolve with appropriate treatment, while chronic cases may indicate underlying systemic issues requiring further investigation. Diagnostic considerations include a thorough patient history, physical examination, and possibly laboratory tests to identify the underlying cause. Differential diagnoses may include conjunctivitis, episcleritis, or other anterior segment disorders that could mimic conjunctival edema.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

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

Audit Risk Factors

  • Common coding errors
  • Documentation gaps
  • Billing challenges

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

Allergy and Immunology

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

Conjunctival edema can significantly impact patient quality of life, leading to discomfort and visual disturbances. Understanding its prevalence in the population is essential for healthcare providers, as it may indicate underlying allergic or systemic conditions. Effective management of conjunctival edema can improve patient outcomes and reduce healthcare utilization by preventing complications associated with untreated conditions.

ICD-9 vs ICD-10

Conjunctival edema can significantly impact patient quality of life, leading to discomfort and visual disturbances. Understanding its prevalence in the population is essential for healthcare providers, as it may indicate underlying allergic or systemic conditions. Effective management of conjunctival edema can improve patient outcomes and reduce healthcare utilization by preventing complications associated with untreated conditions.

Reimbursement & Billing Impact

Reimbursement considerations include verifying the patient's insurance coverage for ophthalmological services and ensuring that the medical necessity is well-documented. Common denials may arise from insufficient documentation or failure to demonstrate the medical necessity of the visit. Coding best practices recommend using the most specific code available and ensuring that all related services are billed appropriately to avoid underpayment.

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 H11.42?

H11.42 covers conjunctival edema resulting from allergic reactions, infections (such as viral conjunctivitis), or systemic conditions like angioedema. It is essential to differentiate it from other conjunctival disorders.

When should H11.42 be used instead of related codes?

H11.42 should be used when the primary diagnosis is conjunctival edema specifically, rather than conjunctivitis or other conjunctival conditions. Proper documentation of the edema's cause is crucial for accurate coding.

What documentation supports H11.42?

Documentation should include a detailed patient history, clinical findings, and any diagnostic tests performed. Evidence of the underlying cause of the edema, such as allergy testing or imaging, should also be included.