How to Accurately Code Corneal Ulcers Using ICD-10 Medical Codes

How to Accurately Code Corneal Ulcers Using ICD-10 Medical Codes A corneal ulcer is an open sore that forms on the cornea. The blog lists the ICD-10 codes for accurately documenting this bacterial eye infection.

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A corneal ulcer is an eye infection that causes an open sore on the cornea (the clear layer in front of the iris and pupil). The cornea is the clear surface that covers the front of the eye, which directs light on to the lens of the eye. A sore can form when the cornea gets inflamed, injured or infected. The sore may feel like something is caught in your eye. It is very painful and can make the eye red, hard to open and sensitive to light. Corneal ulcers generally heal well if treated early and correctly. Without appropriate and timely treatment, this condition can become serious and may lead to severe complications like loss of vision or blindness, perforation of the cornea, displacement of the iris, and destruction of most or all of the tissue in the eye socket. Ophthalmology medical billing and coding can be complex.

Physicians should correctly document all the procedures performed in the medical records.

Outsourcing medical billing and coding tasks can help physicians ensure accurate and timely claim filing and reimbursement.

Typically, most cases of this eye condition are caused by bacterial and fungal infections like acanthamoeba keratitis, herpes simplex keratitis and fungal keratitis, which directly invade the cornea if the corneal surface has been disrupted. Other causes include eye injury, dry eye, inflammatory disorders, eyelid abnormalities, lack of tear production, wearing unsterilized contact lenses and vitamin and nutritional deficiencies. People who happen to wear expired or disposable contact lenses for an extended period (including overnight) are at an increased risk for developing this eye condition.

What Are the Common Signs and Symptoms?

This eye ulcer will often appear as a gray to white opaque or translucent area on the cornea. In some cases, ulcers develop over the entire cornea and may penetrate deeply.

Pus may accumulate behind the cornea, sometimes forming a white layer at the bottom of the cornea (called a hypopyon). On the other hand, some ulcers may be too small to view without adequate magnification and illumination. The deeper the area of the ulcer, the more severe will be its symptoms and complications. Common symptoms include 

Red and sore eye

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Pain in the eye

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Excessive tearing

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Blurred vision

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White spot on the cornea

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Itchy or watery eye

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Inflammation of the eyelids (swelling, redness)

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Pus or thick discharge from your eye

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Sensitivity to light

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Feeling like something is in your eye (foreign body sensation)

How Is a Corneal Ulcer Diagnosed?

As corneal ulcer is a serious vision-threatening condition, people diagnosed with this condition must consult an ophthalmologist who specializes in ocular care and surgery. As part of the diagnosis, eye care specialists will conduct a detailed eye exam, wherein they will enquire about your previous medical history, recent eye injuries and contact lens wear.

Fluorescein eye stain is an important diagnosis test to check for a corneal ulcer. To view an ulcer clearly, an ophthalmologist may apply eye drops (that contain a yellow-green dye called fluorescein), to the surface of your eye, which temporarily stains damaged areas of the cornea. Further, the ophthalmologist uses a microscope (called a slit-lamp) to shine a special violet light onto your eye to look for any damaged areas on your cornea (that are not otherwise visible). In addition, several other diagnosis tests like cultures of scrapings from the ulcer, confocal microscopy and high-definition (HD) photography will also be conducted to capture detailed images of the cornea and other parts of the eye and to identify the exact causes of the eye infection that caused your corneal ulcer. For patients who have an ulcer on their cornea, the eye specialist may numb their eye with eye drops, and then gently scrape the ulcer to get a sample for testing. The test will confirm if the ulcer contains bacteria, fungi, or a virus.

Once the exact causes of corneal ulcer is identified, ophthalmologists may prescribe either an antibacterial, antifungal, antiviral or corticosteroid eye drops to treat the underlying problem. As part of the treatment, physicians will ask patients to avoid wearing contact lenses, touching the eyes unnecessarily, taking other medications and wearing eye makeup.

However, in severe cases, if the ulcer cannot be controlled with medications or if it threatens to perforate the cornea, ophthalmologists may recommend an emergency surgery -- a procedure known as corneal transplant --which involves the surgical removal of the corneal tissue and its replacement with donor tissue.

For appropriate reimbursement, healthcare providers must ensure that the diagnostic codes on insurance billing claims for corneal ulcer infection accurately reflect their specific diagnosis. Ophthalmologists who treat corneal ulcers rely on reputable medical billing companies to code the condition accurately. The following ICD-10 codes are relevant with regard to this bacterial eye infection –

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H16 - Keratitis H16.0 - Corneal ulcer 

H16.00 - Unspecified corneal ulcer

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H16.001 - Unspecified corneal ulcer, right eye

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H16.002 - Unspecified corneal ulcer, left eye

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H16.003 - Unspecified corneal ulcer, bilateral

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H16.009 - Unspecified corneal ulcer, unspecified eye

H16.01 - Central corneal ulcer 

H16.011 - Central corneal ulcer, right eye

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H16.012 - Central corneal ulcer, left eye

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H16.013 - Central corneal ulcer, bilateral

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H16.019 - Central corneal ulcer, unspecified eye

H16.02 - Ring corneal ulcer 

H16.021 - Ring corneal ulcer, right eye

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H16.022 - Ring corneal ulcer, left eye

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H16.023 - Ring corneal ulcer, bilateral

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H16.029 - Ring corneal ulcer, unspecified eye

H16.03 - Corneal ulcer with hypopyon 

H16.031 - Corneal ulcer with hypopyon, right eye

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H16.032 - Corneal ulcer with hypopyon, left eye

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H16.033 - Corneal ulcer with hypopyon, bilateral

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H16.039 - Corneal ulcer with hypopyon, unspecified eye

H16.04 - Marginal corneal ulcer 

H16.041 - Marginal corneal ulcer, right eye

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H16.042 - Marginal corneal ulcer, left eye

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H16.043 - Marginal corneal ulcer, bilateral

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H16.049 - Marginal corneal ulcer, unspecified eye

H16.05 - Mooren's corneal ulcer 

H16.051 - Mooren's corneal ulcer, right eye

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H16.052 - Mooren's corneal ulcer, left eye

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H16.053 - Mooren's corneal ulcer, bilateral

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H16.059 - Mooren's corneal ulcer, unspecified eye

H16.06 - Mycotic corneal ulcer 

H16.061 - Mycotic corneal ulcer, right eye

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H16.062 - Mycotic corneal ulcer, left eye

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H16.063 - Mycotic corneal ulcer, bilateral

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H16.069 - Mycotic corneal ulcer, unspecified eye

H16.07 - Perforated corneal ulcer 

H16.071 - Perforated corneal ulcer, right eye

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H16.072 - Perforated corneal ulcer, left eye

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H16.073 - Perforated corneal ulcer, bilateral

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H16.079 - Perforated corneal ulcer, unspecified eye

H16.1 - Other and unspecified superficial keratitis without conjunctivitis H16.10 - Unspecified superficial keratitis 

H16.101 - Unspecified superficial keratitis, right eye

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H16.102 - Unspecified superficial keratitis ,left eye

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H16.103 - Unspecified superficial keratitis, bilateral

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H16.109 - Unspecified superficial keratitis, unspecified eye

H16.11 - Macular keratitis 

H16.111 - Macular keratitis, right eye

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H16.112 - Macular keratitis, left eye

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H16.113 - Macular keratitis, bilateral

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H16.119 - Macular keratitis, unspecified eye

H16.12 - Filamentary keratitis 

H16.121 - Filamentary keratitis, right eye

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H16.122 - Filamentary keratitis, left eye

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H16.123 - Filamentary keratitis, bilateral

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H16.129 - Filamentary keratitis, unspecified eye

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H16.13 - Photokeratitis 

H16.131 - Photokeratitis, right eye

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H16.132 - Photokeratitis, left eye

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H16.133 - Photokeratitis, bilateral

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H16.139 - Photokeratitis, unspecified eye

H16.14 - Punctate keratitis 

H16.141 - Punctate keratitis, right eye

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H16.142 - Punctate keratitis, left eye

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H16.143 - Punctate keratitis, bilateral

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H16.149 - Punctate keratitis, unspecified eye

The first step towards preventing corneal ulcers is to seek treatment as soon as the symptoms of an eye infection develop or your eye gets injured. Other self-preventive measures include 

Avoid sleeping while wearing your contact lenses

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Apply cool compresses to the affected eye

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Clean and sterilize your contact lenses before and after wearing them

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Wash your hands before touching the eyes or handling the lenses

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Rinse your eyes to remove any foreign objects

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Remove contact lenses whenever the eyes are infected

With proper treatment, most corneal infections improve or heal within two to three weeks.

However, the time of healing may depend on the cause of the ulcer and its size, location, depth and the severity of the infection.

Partnering with a reliable medical billing and coding outsourcing company can ensure accurate reporting of ophthalmology procedures. Such companies have experienced AAPCcertified coders who are highly knowledgeable in the coding and billing guidelines for this specialty and can ensure accurate medical claims.

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