2025 ICD-10-CM code T15.01XD
Foreign body in cornea, right eye, subsequent encounter.
Medical necessity must be established by documenting the presence of the foreign body, associated symptoms impacting vision or comfort, and the need for medical intervention to prevent complications like infection or corneal scarring.
Assessment of the eye, removal of the foreign body, and ensuring appropriate aftercare and follow-up instructions are provided.
In simple words: This code indicates a follow-up visit for a foreign object stuck in the surface of the right eye, specifically the cornea.
The code describes a condition where there is a foreign object present in the cornea of the right eye. This is not the initial encounter for this specific issue.
Example 1: A patient returns to the clinic for a follow-up visit after having a foreign body removed from their right cornea a week prior. The ophthalmologist checks for any signs of infection or complications., A patient presents to the emergency room with a persistent foreign body sensation in their right eye despite initial attempts at removal at an urgent care facility. Further examination reveals a retained foreign body in the cornea, now requiring specialist intervention., A patient with a history of recurrent corneal foreign bodies returns for a scheduled follow-up to discuss preventative measures and management strategies.
Detailed documentation should include the location of the foreign body, method of removal (if applicable during the subsequent encounter), assessment of corneal damage, any associated symptoms, treatment provided, and plan for follow-up care. It should be noted whether this is an initial or subsequent encounter, and any other relevant medical history should be included.
** The "XD" in the code signifies that it refers to a subsequent encounter for this specific condition. For initial encounters, the seventh character would be "XA." If the long-term effects of the foreign body are being addressed, "XS" is used. This code specifically refers to the right eye; for the left eye, use T15.02XD, and for unspecified eye, use T15.00XD, although the latter is discouraged in specialized settings.
- Payment Status: Active
- Specialties:Ophthalmology, Optometry, Emergency Medicine
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Emergency Room - Hospital,Ambulatory Surgical Center, Inpatient Hospital