Exposure keratoconjunctivitis, unspecified eye

This code signifies inflammation of the cornea and conjunctiva resulting from inadequate protection of the ocular surface, often due to incomplete eyelid closure or tear film instability. It indicates a non-specific presentation of this condition, where the laterality of the affected eye is not documented.

Assign this code when documentation indicates keratoconjunctivitis caused by exposure, such as in cases of lagophthalmos, facial nerve palsy, or severe proptosis, and the medical record does not specify whether the right or left eye is affected. Supporting documentation should clearly link the inflammation to an exposure etiology.

• Do not use this code if laterality (right or left eye) is specified; instead, use the more specific H16.211 or H16.212.
• Consider coding any underlying cause of the exposure, such as facial nerve palsy (G51.0) or proptosis (H05.2-), as a secondary diagnosis.
• Distinguish from other forms of keratoconjunctivitis (e.g., allergic, infectious) by ensuring the documentation explicitly states an exposure-related etiology.