2025 ICD-10-CM code H04.12
Dry eye syndrome. Tear film insufficiency, NOS.
Medical necessity for treatment of dry eye syndrome is established by the presence of symptoms and signs affecting the patient's quality of life or visual function. The severity of the condition and the chosen treatment should be justified based on the clinical findings.
Diagnosis involves a comprehensive eye examination, including assessment of the eyelids, cornea, conjunctiva, tear film, and blinking patterns.Tests like tear osmolarity measurement and Schirmer's test may be conducted. Treatment options range from artificial tears and lifestyle modifications to prescription medications and procedures like punctal plugs.
- Chapter 7: Diseases of the eye and adnexa (H00-H59)
- H00-H05: Disorders of eyelid, lacrimal system and orbit
In simple words: Dry eye syndrome means your eyes don't make enough tears or the tears dry up too quickly. This can make your eyes feel dry, scratchy, and irritated.
Dry eye syndrome, also known as keratoconjunctivitis sicca or dry eye disease (DED), is a condition characterized by insufficient lubrication of the eyes due to inadequate tear production or excessive tear evaporation. This leads to a range of symptoms, from mild irritation to severe discomfort and potential damage to the ocular surface.It's often associated with inflammation of the lacrimal glands and ocular surfaces.
Example 1: A 65-year-old female presents with complaints of burning, gritty sensation, and intermittent blurred vision in both eyes, worsening throughout the day. Upon examination, tear film instability and mild corneal staining are observed, consistent with dry eye syndrome., A 30-year-old male, a frequent contact lens wearer, reports dryness, redness, and foreign body sensation in his eyes.Diagnosis of dry eye syndrome is made, and he is advised on proper contact lens hygiene and lubricating eye drops. , A patient with rheumatoid arthritis experiences dry eye symptoms as a side effect of their medication. They are diagnosed with dry eye syndrome secondary to their underlying condition.
Documentation should include details of symptoms (e.g., dryness, burning, grittiness, blurred vision), frequency and duration, any associated factors (e.g., contact lens use, medications, environmental conditions), and findings from the eye examination, including tear film assessment and corneal evaluation. Diagnostic tests conducted (if any) should also be documented.
- Payment Status: Active
- Specialties:Ophthalmology, Optometry
- Place of Service:Office, Outpatient Hospital, Independent Clinic