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2025 ICD-10-CM code H16.141

Punctate keratitis of the right eye.

If the punctate keratitis is caused by an external agent, an additional external cause code should be used.

Medical necessity for the diagnosis and treatment of punctate keratitis is established by the presence of signs and symptoms, such as eye pain, redness, foreign body sensation, photophobia, and visual disturbances, impacting the patient's quality of life and potentially leading to vision impairment if left untreated. The treatment, whether it involves medication, lifestyle adjustments (like contact lens discontinuation), or other interventions, must be directly related to alleviating the symptoms and addressing the underlying cause of the condition.

Diagnosis and treatment of punctate keratitis is typically managed by ophthalmologists or optometrists.

In simple words: This code represents small, dot-like inflammation on the surface of the right eye, known as the cornea.

Punctate keratitis, right eye

Example 1: A patient presents with complaints of foreign body sensation, burning, and excessive tearing in their right eye. Upon examination, the ophthalmologist observes small, pinpoint lesions on the cornea, consistent with punctate keratitis. The diagnosis is confirmed, and treatment is initiated., A patient using contact lenses for an extended period develops redness, pain, and blurry vision in the right eye. The eye doctor diagnoses punctate keratitis, likely due to contact lens overwear, and advises discontinuing lens use and starting appropriate therapy., Following exposure to welding arc without proper eye protection, a patient experiences significant eye pain and light sensitivity. Examination reveals multiple pinpoint corneal abrasions, and the patient is diagnosed with ultraviolet keratitis, a type of punctate keratitis, which is coded as H16.141 if affecting the right eye.

Documentation should include details of the patient's symptoms, the results of the eye examination (including location and characteristics of the punctate lesions), and the suspected cause of the keratitis. Details about any associated conditions, such as dry eye syndrome or contact lens use, should also be documented.

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