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ICD-10 Guide
ICD-10 CodesH11.001

H11.001

Billable

Unspecified pterygium of right eye

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

Code Description

ICD-10 H11.001 is a billable code used to indicate a diagnosis of unspecified pterygium of right eye.

Key Diagnostic Point:

Pterygium is a benign growth of conjunctival tissue that extends onto the cornea, often associated with environmental factors such as UV exposure. The unspecified pterygium of the right eye, coded as H11.001, indicates a lack of specific details regarding the size, symptoms, or progression of the growth. Clinically, patients may present with irritation, redness, and visual disturbances if the pterygium encroaches on the visual axis. Anatomically, the conjunctiva, sclera, and cornea are involved, with the pterygium typically originating from the nasal conjunctiva. Disease progression can vary; some pterygia remain stable, while others may grow and require surgical intervention. Diagnostic considerations include a thorough eye examination, assessment of symptoms, and possibly imaging if the growth is extensive. It is essential to differentiate pterygium from other conjunctival or corneal lesions to ensure appropriate management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Moderate, as pterygium can be confused with other conjunctival lesions.
  • Treatment complexity: Moderate, with options ranging from observation to surgical excision.
  • Documentation requirements: Requires clear documentation of symptoms and examination findings.
  • Coding specificity: Moderate, as the unspecified nature may lead to ambiguity in treatment planning.

Audit Risk Factors

  • Common coding errors: Misclassification of pterygium type or laterality.
  • Documentation gaps: Incomplete patient history or examination findings.
  • Billing challenges: Potential denials if the condition is not clearly documented as affecting the right eye.

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 is prevalent in populations exposed to high UV radiation, impacting quality of life and visual acuity. Understanding the epidemiology of pterygium can aid in preventive measures and public health strategies. Effective management of pterygium can reduce healthcare utilization by minimizing the need for surgical interventions and improving patient outcomes.

ICD-9 vs ICD-10

Pterygium is prevalent in populations exposed to high UV radiation, impacting quality of life and visual acuity. Understanding the epidemiology of pterygium can aid in preventive measures and public health strategies. Effective management of pterygium can reduce healthcare utilization by minimizing the need for surgical interventions and improving patient outcomes.

Reimbursement & Billing Impact

impact reimbursement. Common denials may arise if the documentation does not sufficiently demonstrate the need for surgical intervention or if the condition is not clearly defined. Best practices include using precise language in clinical notes and ensuring that all relevant details are included to support the coding and billing process.

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 H11.001?

H11.001 covers unspecified pterygium of the right eye, which may present as a growth on the conjunctiva that extends onto the cornea. It does not specify the size or symptoms associated with the pterygium.

When should H11.001 be used instead of related codes?

H11.001 should be used when the pterygium is confirmed in the right eye but lacks specific details regarding its characteristics or symptoms. If more information is available, such as laterality or specific symptoms, a more specific code should be selected.

What documentation supports H11.001?

Documentation should include a comprehensive eye examination report detailing the presence of pterygium in the right eye, associated symptoms, and any treatment considerations. Photographic evidence may also support the diagnosis.