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ICD-10 Guide
ICD-10 CodesH16.102

H16.102

Billable

Unspecified superficial keratitis, left eye

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

Code Description

ICD-10 H16.102 is a billable code used to indicate a diagnosis of unspecified superficial keratitis, left eye.

Key Diagnostic Point:

Unspecified superficial keratitis of the left eye refers to inflammation of the cornea that is not attributed to a specific cause. Clinically, patients may present with symptoms such as redness, tearing, photophobia, and blurred vision. The cornea, which is the transparent front part of the eye, plays a crucial role in focusing light and protecting the inner structures of the eye. Superficial keratitis can arise from various etiologies, including infections (viral, bacterial, or fungal), environmental factors (such as exposure to UV light or chemicals), or allergic reactions. Disease progression can vary; if untreated, superficial keratitis may lead to more severe corneal damage or scarring. Diagnostic considerations include a thorough patient history, slit-lamp examination, and possibly corneal scraping or cultures to identify infectious agents. The lack of specificity in this code indicates that the underlying cause of keratitis has not been determined, necessitating further investigation and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Requires differential diagnosis to rule out specific causes of keratitis.
  • Treatment complexity: Management may involve topical antibiotics, antivirals, or corticosteroids depending on the underlying cause.
  • Documentation requirements: Detailed clinical notes are essential to justify the diagnosis and treatment plan.
  • Coding specificity: The unspecified nature of the code may lead to challenges in accurately capturing the patient's condition.

Audit Risk Factors

  • Common coding errors: Misuse of unspecified codes when a more specific diagnosis is available.
  • Documentation gaps: Incomplete patient history or examination findings may lead to coding inaccuracies.
  • Billing challenges: Insufficient documentation may result in claim denials or delays in reimbursement.

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

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The clinical significance of H16.102 lies in its potential to indicate underlying conditions that may affect vision and overall eye health. Superficial keratitis can lead to increased healthcare utilization due to recurrent visits and treatments. Understanding the epidemiology of keratitis is crucial, as it can affect diverse populations, particularly those with risk factors such as contact lens wearers or individuals with compromised immune systems. Quality measures may include tracking treatment outcomes and patient satisfaction related to eye care.

ICD-9 vs ICD-10

The clinical significance of H16.102 lies in its potential to indicate underlying conditions that may affect vision and overall eye health. Superficial keratitis can lead to increased healthcare utilization due to recurrent visits and treatments. Understanding the epidemiology of keratitis is crucial, as it can affect diverse populations, particularly those with risk factors such as contact lens wearers or individuals with compromised immune systems. Quality measures may include tracking treatment outcomes and patient satisfaction related to eye care.

Reimbursement & Billing Impact

Reimbursement considerations include ensuring that the documentation supports the medical necessity of the services provided. Common denials may arise from insufficient documentation or failure to demonstrate the need for treatment. Best practices include thorough clinical notes, clear treatment plans, and follow-up documentation to support ongoing 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 H16.102?

H16.102 covers cases of superficial keratitis in the left eye where the specific cause is not identified. This may include viral, bacterial, or allergic keratitis that has not been further classified.

When should H16.102 be used instead of related codes?

H16.102 should be used when the clinician has determined that the keratitis is superficial and has not identified a specific etiology. If a specific cause is known, a more precise code should be selected.

What documentation supports H16.102?

Documentation should include a comprehensive eye examination, patient symptoms, treatment plan, and any diagnostic tests performed to rule out specific causes of keratitis.