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2025 ICD-10-CM code H16.0

Corneal ulcer.

Use an external cause code following the code for the eye condition, if applicable, to identify the cause of the eye condition. This code excludes certain conditions originating in the perinatal period (P04-P96), certain infectious and parasitic diseases (A00-B99), complications of pregnancy, childbirth, and the puerperium (O00-O9A), congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99), diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-), endocrine, nutritional, and metabolic diseases (E00-E88), injury (trauma) of eye and orbit (S05.-), injury, poisoning, and certain other consequences of external causes (S00-T88), neoplasms (C00-D49), symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94), and syphilis-related eye disorders (A50.01, A50.3-, A51.43, A52.71).

Medical necessity for treatment of a corneal ulcer is established by the presence of signs and symptoms indicating a disruption of the corneal epithelium, posing a risk to vision if left untreated.The documentation should support the severity of the ulcer and the chosen treatment plan.

Diagnosis and treatment of corneal ulcers fall under the purview of ophthalmologists. They are responsible for determining the underlying cause, assessing the severity of the ulcer, and prescribing the appropriate treatment, which may include medication, eye patching, or in severe cases, surgery.

In simple words: A corneal ulcer is like a sore on the front surface of your eye. It can be painful and cause problems with your vision.

A corneal ulcer is an open sore on the cornea, the clear front surface of the eye.It's often caused by infection, injury, or other eye conditions. Corneal ulcers can range in severity from superficial to deep, affecting different layers of the cornea.

Example 1: A patient presents with a red, painful eye, light sensitivity, and blurry vision after scratching their eye with a fingernail. Examination reveals a corneal ulcer., A contact lens wearer develops a severe corneal infection, leading to a corneal ulcer with associated discharge and significant pain. , A patient with dry eye syndrome and a history of corneal abrasions develops a persistent corneal ulcer despite initial treatment with lubricating eye drops.

Documentation should include the location, size, and depth of the ulcer; the presence of any associated signs or symptoms like discharge, pain, or vision changes; the suspected cause of the ulcer; and the prescribed treatment plan.It is also essential to document any prior history of eye conditions, contact lens use, or recent trauma.

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