Primary lacrimal gland atrophy, bilateral lacrimal glands

This code describes a condition where both lacrimal glands, responsible for tear production, have undergone a reduction in size and function due to primary atrophy. This leads to decreased tear production, often resulting in severe dry eye symptoms. It signifies a non-secondary cause of lacrimal gland degeneration.

Use this code when documentation explicitly states primary atrophy of both lacrimal glands. This diagnosis is typically made after ruling out secondary causes of lacrimal gland dysfunction, such as autoimmune diseases (e.g., Sjögren's syndrome) or trauma. Clinical notes should support bilateral involvement and the primary nature of the atrophy.

• Ensure documentation specifies "primary" atrophy and "bilateral" involvement; otherwise, a more general or unilateral code may be appropriate.
• Distinguish from secondary lacrimal gland atrophy, which would be coded based on the underlying cause.
• Consider co-reporting codes for associated dry eye symptoms (e.g., H04.12x) if documented.