Unspecified superficial keratitis, unspecified eye
ICD-10 H16.109 is a billable code used to indicate a diagnosis of unspecified superficial keratitis, unspecified eye.
Unspecified superficial keratitis refers to inflammation of the cornea that is not associated with a specific underlying cause or condition. Clinically, patients may present with symptoms such as redness, tearing, photophobia, and a sensation of grittiness in the eye. The anatomy involved primarily includes the cornea, which is the transparent front part of the eye, along with potential involvement of the conjunctiva and sclera. Disease progression can vary; while some cases may resolve spontaneously, others can lead to complications such as corneal scarring or vision impairment if left untreated. Diagnostic considerations include a thorough patient history, slit-lamp examination, and possibly corneal scraping or cultures to rule out infectious causes. Given the nonspecific nature of this diagnosis, it is crucial for healthcare providers to document any associated symptoms and potential triggers to guide appropriate management.
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
H16.109 covers cases of superficial keratitis that do not have a specified etiology, including those caused by environmental factors, allergens, or idiopathic reasons. It is essential to document any associated symptoms or potential triggers to aid in management.
H16.109 should be used when the keratitis is superficial and no specific cause has been identified. If a specific etiology, such as infectious or autoimmune causes, is known, then more specific codes should be utilized.
Documentation should include a comprehensive eye examination report, patient history detailing symptoms and duration, any diagnostic tests performed, and a treatment plan. This information is crucial for justifying the use of H16.109.
