In simple words: Dry eye syndrome means your eyes don't make enough tears or the tears dry up too quickly. This causes inflammation in the tear glands and the surface of your eyes. This specific code is used when the doctor doesn't say whether the problem is in the right eye, left eye, or both eyes.

Dry eye syndrome refers to a tear film disorder characterized by tear deficiency or excessive tear evaporation.It involves inflammation of the lacrimal glands and ocular surfaces. This code specifies dry eye syndrome affecting an unspecified lacrimal gland (meaning it is not specified whether the right, left, or both glands are affected).

Example 1: A 60-year-old female patient presents with complaints of burning, irritation, and a foreign body sensation in her eyes. Upon examination, the physician diagnoses dry eye syndrome, but doesn't specify which lacrimal gland is affected. H04.129 is used., A patient with a history of rheumatoid arthritis complains of dry eyes. The physician diagnoses dry eye syndrome, but the documentation does not specify which eye is affected. H04.129 is applied., A patient reports blurred vision, light sensitivity, and watery eyes.The physician determines the cause is dry eye syndrome originating in the lacrimal gland(s), but laterality is not documented. H04.129 is the appropriate code.

Documentation should clearly describe the symptoms, including burning, irritation, foreign body sensation, redness, light sensitivity, watery eyes, and blurred vision.The affected eye(s) or lacrimal gland(s) should be specified when possible.Clinical findings from the eye exam should also be included. If known, any underlying causes or contributing factors, like medication use or systemic diseases, should be noted.