Unspecified corneal ulcer, bilateral

This code represents an inflammatory lesion of the cornea, characterized by a defect in the corneal epithelium and stroma, affecting both eyes. The specific cause or type of corneal ulcer is not documented or determined. It indicates a general diagnosis of corneal ulceration without further etiological or morphological detail.

Use this code when documentation indicates a corneal ulcer is present in both eyes, but the provider has not specified the type (e.g., infectious, sterile, neurotrophic) or the underlying cause. This is typically an interim or less specific diagnosis when further investigation is pending or when the exact etiology cannot be determined.

• Avoid using this code if a more specific type of corneal ulcer (e.g., infectious, central, marginal) is documented; always code to the highest level of specificity.
• Ensure documentation clearly states "bilateral" involvement; otherwise, a unilateral or unspecified eye code would be more appropriate.
• Consider querying the provider for more specific details regarding the ulcer's etiology or morphology to allow for more precise coding.