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2025 ICD-10-CM code S05.0

Injury of the conjunctiva and corneal abrasion without a foreign body.

Use additional code to identify any retained foreign body, if applicable (Z18.-).If there is a foreign body involved, code S05.0 is not appropriate.The external cause of the injury should also be coded using codes from Chapter 20 of ICD-10-CM.

Medical necessity is established based on the presence of a corneal abrasion and conjunctival irritation, along with the potential for infection and visual impairment.The severity of the injury and the need for treatment should be documented to justify the medical services provided.

The clinical responsibility for managing an injury of the conjunctiva and corneal abrasion without a foreign body involves a comprehensive evaluation by a healthcare provider, including taking a detailed patient history, performing a thorough physical examination of the eye, assessing visual acuity, and determining the need for additional imaging studies. Treatment may involve cleaning the abrasion, pain management with analgesics, and prevention of infection with antibiotics.Referral to an ophthalmologist may be necessary depending on the severity of the injury.

IMPORTANT:Excludes foreign body in conjunctival sac (T15.1) and foreign body in cornea (T15.0).

In simple words: This code describes a minor eye injury involving a scratch on the surface of the eye (cornea) and some damage to the lining of the eyelid and eyeball (conjunctiva).It doesn't include injuries caused by something left in the eye.Treatment usually involves cleaning and medicine.

This ICD-10-CM code classifies injuries involving trauma to the conjunctiva (the membrane lining the eyelids and eyeball) and a corneal abrasion (scratch on the cornea), specifically excluding cases with retained foreign bodies.The injury may manifest as pain, redness, swelling, watering eyes, discharge, and reduced visual function. Diagnosis relies on patient history, physical examination (assessing redness, swelling, visual acuity, and eye movement), and potentially imaging (X-rays). Treatment typically includes cleaning the abrasion and administering analgesics for pain and antibiotics to prevent infection.

Example 1: A patient presents to the emergency room after rubbing their eye vigorously. Examination reveals a superficial scratch on the cornea and mild inflammation of the conjunctiva. No foreign body is present.The physician cleans the abrasion, prescribes antibiotic eye drops, and sends the patient home with instructions for pain management., A child falls and scrapes their eye on the playground. The parent brings them to a pediatrician's office. The pediatrician notes a small abrasion on the cornea and mild conjunctival irritation, with no foreign body detected.The abrasion is cleaned, antibiotic ointment is applied, and the parent is instructed to monitor for infection or worsening symptoms., During a contact sports game, an athlete suffers a minor eye injury.The team physician finds a small corneal abrasion and mild conjunctival irritation without a foreign body.They provide immediate treatment and suggest that the athlete refrain from participating in the game.

* Detailed patient history including mechanism of injury.* Physical examination findings, specifically noting the presence or absence of a foreign body, the location and size of the abrasion, level of conjunctival irritation, and visual acuity.* Treatment provided, including medications administered and instructions for follow-up care.* Imaging reports, if any (e.g., X-rays).

** This code is for initial encounters (A) and subsequent encounters (D).Sequela (S) codes may also be used to track long-term effects.

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