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2025 ICD-10-CM code H04.122

Dry eye syndrome of the left lacrimal gland.

Use H04.122 when the dry eye condition is specifically attributed to the left lacrimal gland. Do not use this code for keratoconjunctivitis sicca, which has specific codes (H16.2- or M35.01 depending on its relation to Sjogren’s syndrome).

Medical necessity for treatment of dry eye syndrome of the left lacrimal gland must be supported by documentation of symptoms, impaired function, and the potential for corneal damage if left untreated.

The physician is responsible for diagnosing dry eye syndrome based on the patient's medical history, symptoms, and a thorough eye examination. Treatment may include over-the-counter artificial tears, prescription eye drops (antibiotic or anti-inflammatory), tear duct plugs, or tear-stimulating medications.

In simple words: Dry eye syndrome means your eyes don't make enough tears or the tears dry up too quickly. This can cause inflammation and irritation, especially in the tear glands. This code refers to dry eye affecting the tear gland of your left eye.

Dry eye syndrome, also known as tear film insufficiency, is characterized by inflammation of the lacrimal glands and ocular surfaces, leading to tear deficiency or excessive tear evaporation. This code specifies the condition affecting the left lacrimal gland.

Example 1: A patient presents with complaints of burning, irritation, and a foreign body sensation in their left eye. Upon examination, the physician diagnoses dry eye syndrome specifically affecting the left lacrimal gland., A patient with rheumatoid arthritis experiences worsening dry eye symptoms in their left eye. The physician determines the left lacrimal gland is primarily affected and bills accordingly., A patient using antihistamines for allergies develops dry eye. The ophthalmologist diagnoses dry eye syndrome concentrated in the left lacrimal gland after a detailed examination.

Documentation should include the patient's symptoms, relevant medical history (including medications and pre-existing conditions), examination findings (such as tear film assessment and examination of the eyelids and cornea), and the diagnosis of dry eye syndrome affecting the left lacrimal gland.

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