2025 ICD-10-CM code H16.142
Punctate keratitis of the left eye.
Medical necessity for the treatment of punctate keratitis stems from the potential for vision impairment or complications if the condition is left untreated. The medical record should clearly document the patient's symptoms, examination findings, and the rationale for the chosen treatment plan.
Diagnosis and treatment of punctate keratitis typically falls under the purview of ophthalmologists and optometrists. They are responsible for conducting a thorough eye examination, including visual acuity tests, slit-lamp examination, and corneal staining, to confirm the diagnosis. Treatment may involve lubricating eye drops, antibiotic ointments or eye drops if an infection is suspected, and addressing the underlying cause of the inflammation. Patient education on proper eye care and hygiene is also crucial.
- Diseases of the eye and adnexa (H00-H59)
- Disorders of sclera, cornea, iris and ciliary body (H15-H22)
In simple words: Punctate keratitis is a condition where the surface of your left eye, specifically the cornea (the clear front part of your eye), develops tiny dots or spots due to inflammation.
Punctate keratitis is an inflammation of the cornea characterized by small, pinpoint erosions or opacities on its surface. This condition affects the left eye.
Example 1: A 30-year-old female presents with complaints of redness, foreign body sensation, and blurry vision in her left eye after spending a day at the beach. Upon examination, the ophthalmologist diagnoses her with punctate keratitis of the left eye and prescribes lubricating eye drops., A welder experiences sudden pain and decreased vision in his left eye after his protective mask slipped during work. The emergency physician diagnoses him with photokeratitis, a form of punctate keratitis, caused by ultraviolet radiation exposure., A patient with a history of contact lens overuse complains of discomfort and light sensitivity in her left eye. The optometrist diagnoses her with contact lens-induced punctate keratitis and advises her to discontinue lens wear and use lubricating eye drops.
Detailed documentation of the patient's symptoms (e.g., pain, redness, tearing, photophobia), the results of the eye examination, including visual acuity measurements and slit-lamp findings, and the presence of any contributing factors (e.g., contact lens wear, dry eye, UV exposure) is crucial for accurate coding.
- Specialties:Ophthalmology, Optometry
- Place of Service:Office, Outpatient Hospital, Emergency Room - Hospital