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2025 ICD-10-CM code H16.221

Keratoconjunctivitis sicca, not specified as Sjogren's, right eye.

Ensure proper laterality is documented and coded. If Sjogren's syndrome is present, use M35.01. Use H04.12- for “tear film insufficiency NOS”.

Medical necessity should be supported by documentation of diagnostic testing or clinical findings to establish the diagnosis of keratoconjunctivitis sicca.

Diagnosis and treatment of keratoconjunctivitis sicca.

IMPORTANT For Sjogren's syndrome with keratoconjunctivitis, use M35.01. If the condition affects the left eye, use H16.222. For bilateral involvement, use H16.223. For unspecified eye, use H16.229. If the provider documents "tear film insufficiency NOS," consider using H04.12-.

In simple words: Dry eye condition affecting the right eye, not related to Sjogren's syndrome.

Keratoconjunctivitis sicca, not specified as Sjogren's, right eye. This condition refers to chronic dryness of the conjunctiva and cornea of the right eye, not associated with Sjogren's syndrome.

Example 1: A patient presents with complaints of dry eye in their right eye. After examination, the physician diagnoses keratoconjunctivitis sicca, not specified as Sjogren's, right eye., Patient reports persistent dryness, scratchiness, and burning sensation in their right eye. The ophthalmologist diagnoses keratoconjunctivitis sicca, ruling out Sjogren's syndrome, and prescribes lubricating eye drops., During a routine eye exam, the doctor observes dryness in the patient's right eye and performs tests to confirm keratoconjunctivitis sicca, not related to Sjogren's syndrome.

Detailed clinical findings related to dry eye symptoms, laterality, and exclusion of Sjogren's syndrome are required for accurate coding.

  • Specialties:Ophthalmology, Optometry
  • Place of Service:Office, Outpatient Hospital, Inpatient Hospital
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