Dry eye syndrome of unspecified lacrimal gland

This code represents a chronic condition characterized by insufficient tear production or poor tear quality, leading to ocular surface dryness, irritation, and discomfort. It specifically indicates that the dry eye syndrome is due to an issue with an unspecified lacrimal gland.

Use this code when documentation confirms a diagnosis of dry eye syndrome, and the specific lacrimal gland (e.g., right, left, bilateral) affected is not specified by the provider. This code is appropriate when the etiology points to lacrimal gland dysfunction but laterality is unknown or not documented.

• Do not use if laterality (right, left, bilateral) is documented; instead, choose a more specific code from the H04.12 series.
• Ensure the documentation clearly states "dry eye syndrome" and implies lacrimal gland involvement, even if unspecified.
• Consider querying the provider for laterality if it's missing and clinically relevant for more precise coding.