Keratoconjunct sicca, not specified as Sjogren's, bilateral

This code describes a chronic condition characterized by dryness of both eyes due to insufficient tear production or excessive tear evaporation, not specifically linked to Sjogren's syndrome. Patients typically experience irritation, foreign body sensation, and blurred vision. It represents a non-Sjogren's related form of dry eye affecting both eyes.

Use this code when documentation clearly indicates bilateral keratoconjunctivitis sicca, and Sjogren's syndrome has been explicitly ruled out or is not mentioned as the underlying cause. This code is appropriate for idiopathic dry eye or dry eye secondary to other systemic conditions not specified as Sjogren's. Documentation should specify "bilateral" involvement.

• Ensure documentation specifies "bilateral" involvement; otherwise, use a code for unspecified or unilateral.
• If Sjogren's syndrome is documented as the cause, a different code from the H16.23- series (Keratoconjunctivitis sicca due to Sjogren's) should be used.
• Always review the medical record for any underlying systemic conditions that may be contributing to the dry eye, and code them as secondary diagnoses if applicable.