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2025 ICD-10-CM code H16.229

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

Do not use this code if the laterality is known. Use H16.221 for the right eye, H16.222 for the left eye, and H16.223 for both eyes. Also, exclude Sjogren's syndrome (M35.0-) before assigning this code.

Medical necessity is established by the presence of signs and symptoms of keratoconjunctivitis sicca, impacting the patient's visual function and/or quality of life.

Diagnosis and treatment of dry eye conditions.

In simple words: Dry eye not due to Sjogren’s syndrome, affecting one or both eyes, without specifying which.

Keratoconjunctivitis sicca, not specified as Sjogren's, unspecified eye. This condition describes dry eye not related to Sjogren's syndrome affecting an unspecified eye.

Example 1: A patient presents with complaints of dry eyes, foreign body sensation, and blurry vision. Upon examination, the ophthalmologist diagnoses keratoconjunctivitis sicca. The patient does not have Sjogren's syndrome, and the condition affects an eye (right or left is unspecified)., A patient with a history of blepharitis reports persistent dryness in one eye (side unspecified). After a thorough evaluation ruling out Sjogren's syndrome, the physician confirms the diagnosis as keratoconjunctivitis sicca., An elderly patient presents with eye irritation and difficulty wearing contact lenses due to dryness. The symptoms are present in one eye (not specified), and the diagnosis is keratoconjunctivitis sicca. Sjogren's is ruled out through relevant testing.

Symptoms, clinical findings from eye examination (e.g., Schirmer's test, tear breakup time), and exclusion of Sjogren's syndrome.

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