Perforated corneal ulcer, unspecified eye

This code signifies a full-thickness defect in the corneal stroma, extending through Bowman's layer and Descemet's membrane, resulting in a perforation. This condition is typically caused by severe infection, trauma, or autoimmune processes, leading to a breach in the integrity of the cornea.

Use this code when documentation clearly indicates a perforated corneal ulcer but the specific eye affected (right or left) is not specified. This diagnosis is often supported by slit-lamp examination findings detailing a through-and-through corneal defect with potential aqueous humor leakage or iris prolapse.

• Ensure documentation explicitly states "perforated" and not just "severe" or "deep" ulcer.
• Avoid using this code if the laterality (right or left eye) is documented; use the more specific H16.071 or H16.072.
• Consider co-reporting an underlying cause (e.g., bacterial infection B95.-, viral infection B00.5) if identified and documented.