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2025 ICD-10-CM code T15.02XA

Foreign body in cornea, left eye, initial encounter.

Always specify the laterality (right or left eye) when coding corneal foreign bodies. Use appropriate 7th characters to indicate the encounter status (A, D, S).

Modifiers may be appropriate depending on the circumstances of the procedure (e.g., 59 for distinct procedural service, -25 for significant, separately identifiable E/M service).Consult your payer's guidelines for modifier usage.

Medical necessity is established by the presence of a corneal foreign body causing symptoms such as pain, discomfort, visual impairment, or risk of infection.Documentation should clearly support the need for removal.

The ophthalmologist or other qualified eye care professional is responsible for the diagnosis and treatment of corneal foreign bodies. This includes removing the foreign body, assessing corneal damage, and providing appropriate aftercare instructions.

IMPORTANT:T15.02XD (subsequent encounter), T15.02XS (sequela).Use additional code W44.- if the foreign body entered through a natural orifice, and Z18.- for retained foreign body if applicable.

In simple words: A foreign object is lodged in the cornea of the patient's left eye, and this is the first time the patient is seeking medical attention for this issue.

This ICD-10-CM code classifies the diagnosis of a foreign body present in the cornea of the left eye during the initial encounter.It signifies the first instance of this condition being addressed by a healthcare provider.The code specifically indicates the location (left eye cornea) and the encounter status (initial).

Example 1: A construction worker gets a piece of metal embedded in his left cornea while working. This is his first visit to the doctor for this., A child rubs their eye and a small piece of sand becomes lodged in their left cornea. This is the initial treatment for the injury., During a contact lens insertion, a tiny fiber from the lens becomes embedded in the patient’s left cornea.This is the first medical visit addressing this injury.

Detailed ophthalmologic examination findings, including the type and location of the foreign body within the cornea of the left eye, should be documented.Procedure notes should clearly describe the removal technique and any complications encountered.Images (such as slit-lamp photographs) are valuable additions to the medical record.

** This code should be used in conjunction with appropriate CPT codes to accurately reflect the services performed.Refer to the official ICD-10-CM guidelines and the latest NCCI edits for the most current and accurate coding practices.Always code to the highest level of specificity.

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