Unspecified superficial keratitis, right eye
ICD-10 H16.101 is a billable code used to indicate a diagnosis of unspecified superficial keratitis, right eye.
Unspecified superficial keratitis of the right eye refers to inflammation of the cornea that is not associated with a specific underlying condition. Clinically, patients may present with symptoms such as redness, tearing, photophobia, and a sensation of grittiness in the affected eye. The cornea, which is the transparent front part of the eye, plays a crucial role in vision and is composed of several layers, including the epithelium, stroma, and endothelium. Superficial keratitis primarily affects the epithelial layer, leading to potential corneal abrasions or erosions. Disease progression can vary; if left untreated, superficial keratitis may lead to more severe corneal damage or secondary infections. Diagnostic considerations include a thorough ocular examination, slit-lamp evaluation, and possibly corneal staining with fluorescein to assess for epithelial defects. It is important to differentiate this condition from other forms of keratitis, such as bacterial or viral keratitis, which may require different management strategies.
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
H16.101 covers unspecified superficial keratitis, which may arise from various causes such as environmental irritants, allergic reactions, or contact lens wear. It does not specify a particular etiology, allowing for broader application in clinical settings.
H16.101 should be used when the keratitis is superficial and unspecified, and when there is no clear diagnosis of a specific type of keratitis, such as bacterial or viral. It is important to document the absence of specific findings that would necessitate a more specific code.
Documentation should include a detailed history of symptoms, clinical findings from the eye examination, and any diagnostic tests performed. Notes should clearly indicate the diagnosis of unspecified superficial keratitis and the rationale for this classification.
