Unspecified superficial keratitis, bilateral
ICD-10 H16.103 is a billable code used to indicate a diagnosis of unspecified superficial keratitis, bilateral.
Unspecified superficial keratitis, bilateral, refers to inflammation of the cornea that is not attributed to a specific underlying cause. Clinically, patients may present with symptoms such as redness, tearing, photophobia, and blurred vision. The cornea, which is the clear front part of the eye, plays a crucial role in focusing light and protecting the inner structures of the eye. In bilateral cases, both eyes are affected, which can complicate the clinical picture. Disease progression may vary; while some cases resolve spontaneously, others can lead to more severe complications if left untreated. Diagnostic considerations include a thorough patient history, slit-lamp examination, and possibly corneal scraping to rule out infectious causes. The absence of specific etiological factors makes this diagnosis challenging, requiring careful monitoring and management to prevent potential vision loss.
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
H16.103 encompasses cases of superficial keratitis that do not have a specified etiology, including allergic reactions, environmental irritants, or idiopathic causes. It is essential to rule out infectious keratitis or other corneal pathologies.
H16.103 should be used when the keratitis is bilateral and unspecified, particularly when the clinician has ruled out specific causes but the patient presents with symptoms of superficial keratitis affecting both eyes.
Documentation should include a detailed clinical examination, patient symptoms, any treatments attempted, and follow-up notes. Evidence of ruling out other conditions is also critical.
