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2025 ICD-10-CM code H04.121

Dry eye syndrome of the right lacrimal gland.

It’s crucial to distinguish H04.121 (dry eye syndrome of the right lacrimal gland) from other related codes. For instance, if the dry eye is a result of Sjogren's syndrome, M35.01 should be used. If it manifests as keratoconjunctivitis sicca without Sjogren's, then H16.2- is appropriate. If there's another underlying condition causing the dry eye, it should be coded as well.

Medical necessity for treatment of dry eye syndrome is established by the presence of signs and symptoms impacting the patient's visual function or causing significant discomfort.Documentation should support the severity of the condition and the rationale for the chosen treatment.

Diagnosis of dry eye syndrome involves evaluating the patient's symptoms, medical history, and conducting an eye exam. The exam may include tests such as Schirmer's test, tear break-up time, and assessment of the cornea and eyelids.Treatment options range from over-the-counter artificial tears to prescription medications and procedures like punctal plugs.

IMPORTANT If the dry eye is related to Sjogren's syndrome, use M35.01. If unrelated to Sjogren's syndrome but presenting as keratoconjunctivitis sicca, use H16.2-.

In simple words: Dry eye syndrome is a condition where your eyes don't make enough tears or the tears evaporate too quickly. This can cause your eyes to feel dry, irritated, and uncomfortable. This specific code refers to dry eye affecting the tear gland located above your right eye.

Dry eye syndrome, also known as keratoconjunctivitis sicca, is a common disorder affecting the tear film and ocular surface. This condition is characterized by a deficiency in tear production or excessive tear evaporation.In this specific code, the dry eye syndrome is localized to the right lacrimal gland.

Example 1: A 65-year-old female presents with complaints of burning and irritation in her right eye. Upon examination, the physician diagnoses dry eye syndrome specifically affecting the right lacrimal gland., A patient with rheumatoid arthritis experiences persistent dryness and discomfort in their right eye.After further evaluation, the physician determines the cause to be dry eye syndrome localized to the right lacrimal gland., Following a cosmetic eyelid surgery, a patient develops dry eye symptoms in their right eye. The ophthalmologist confirms dry eye syndrome originating from the right lacrimal gland.

Documentation should include the patient's symptoms, relevant medical history (including medications and pre-existing conditions), examination findings (including any diagnostic tests performed), and the physician's assessment confirming dry eye syndrome affecting the right lacrimal gland. Unsuccessful prior treatments for dry eye should also be documented if applicable.

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