Unspecified superficial keratitis, bilateral

This code signifies an inflammation of the cornea's outermost layers, affecting both eyes, where the specific type of superficial keratitis is not documented. It indicates a general corneal surface irritation or infection without further etiological or morphological detail.

Utilize this code when documentation specifies superficial keratitis affecting both eyes, but the physician has not identified the precise cause (e.g., viral, bacterial, exposure) or specific type (e.g., punctate, filamentary). This code is appropriate when the medical record explicitly states "unspecified superficial keratitis, bilateral."

• Avoid using this code if more specific documentation regarding the type or cause of keratitis is available (e.g., H16.113 for punctate keratitis).
• Ensure the documentation clearly indicates bilateral involvement; otherwise, use a unilateral code (e.g., H16.101 or H16.102).
• Always query the provider for greater specificity if "unspecified" is documented, as a more precise diagnosis often leads to better patient care and more accurate coding.