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ICD-10 Guide
ICD-10 CodesH11.00

H11.00

Non-billable

Unspecified pterygium of eye

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

Code Description

ICD-10 H11.00 is a used to indicate a diagnosis of unspecified pterygium of eye.

Key Diagnostic Point:

H11.00 refers to an unspecified pterygium of the eye, a benign growth of conjunctival tissue that can extend onto the cornea. Clinically, pterygia often present as a triangular, fleshy growth that can cause discomfort, redness, and visual disturbances if it encroaches on the visual axis. The anatomy involved includes the conjunctiva, which is the membrane covering the white part of the eye, and the cornea, the clear front surface of the eye. Disease progression can vary; some pterygia remain stable, while others may grow and require surgical intervention. Diagnostic considerations include a thorough eye examination, where the growth's size, location, and symptoms are evaluated. Differential diagnoses may include pinguecula, a similar but less invasive condition. The presence of symptoms such as irritation or visual impairment may guide the decision for treatment, which can range from observation to surgical excision in more severe cases.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Moderate, as distinguishing pterygium from other conjunctival lesions can be challenging.
  • Treatment complexity: Moderate, with options ranging from monitoring to surgical intervention.
  • Documentation requirements: Requires detailed clinical notes to justify the diagnosis and treatment plan.
  • Coding specificity: Medium, as the unspecified nature of the code may lead to ambiguity in clinical scenarios.

Audit Risk Factors

  • Common coding errors: Misuse of related codes due to lack of specificity.
  • Documentation gaps: Incomplete clinical notes that do not clearly outline the diagnosis and treatment rationale.
  • Billing challenges: Potential for denials if the documentation does not support the necessity of treatment.

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

Pterygium can significantly affect quality of life, leading to discomfort and visual impairment in affected individuals. The prevalence of pterygium is higher in populations exposed to UV light, making it a public health concern in sunny regions. Understanding the epidemiology of pterygium can aid in developing preventive strategies and improving patient outcomes. Quality measures may include tracking surgical outcomes and patient satisfaction post-treatment.

ICD-9 vs ICD-10

Pterygium can significantly affect quality of life, leading to discomfort and visual impairment in affected individuals. The prevalence of pterygium is higher in populations exposed to UV light, making it a public health concern in sunny regions. Understanding the epidemiology of pterygium can aid in developing preventive strategies and improving patient outcomes. Quality measures may include tracking surgical outcomes and patient satisfaction post-treatment.

Reimbursement & Billing Impact

Reimbursement may depend on the severity of symptoms and the necessity of surgical intervention. Common denials can occur if the documentation does not clearly justify the procedure performed. It is essential to include detailed clinical notes, including the patient's symptoms, examination findings, and the rationale for treatment. Adhering to coding best practices and ensuring that all relevant information is captured can help mitigate billing challenges.

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 H11.00?

H11.00 covers unspecified pterygium, which may not have clear symptoms or may not be documented as affecting a specific eye. It is important to differentiate it from other conjunctival lesions like pinguecula or conjunctival cysts.

When should H11.00 be used instead of related codes?

H11.00 should be used when the pterygium is not specified as affecting either the right or left eye, or when the clinical details do not allow for a more specific code. It is essential to ensure that the documentation supports the use of this unspecified code.

What documentation supports H11.00?

Documentation should include a detailed description of the pterygium, including its size, location, symptoms, and any treatment provided. Clinical notes should clearly outline the rationale for the diagnosis and any interventions performed.