Keratoconjunct sicca, not specified as Sjogren's, unsp eye

This code describes dry eye syndrome, specifically keratoconjunctivitis sicca, where the underlying cause is not attributed to Sjögren's syndrome. It indicates inflammation of both the cornea and conjunctiva due to insufficient tear production or excessive tear evaporation, leading to ocular dryness and irritation. The "unspecified eye" designation means the laterality of the condition is not documented.

Use this code when documentation clearly indicates a diagnosis of keratoconjunctivitis sicca without specifying Sjögren's syndrome as the etiology, and the medical record does not specify whether the condition affects the right, left, or both eyes. This applies to patients presenting with symptoms such as gritty sensation, burning, foreign body sensation, or blurred vision due to dry eyes.

• Avoid using this code if the documentation specifies laterality (e.g., right eye, left eye, bilateral); instead, use the more specific codes (H16.221, H16.222, H16.223).
• Do not use this code if Sjögren's syndrome is identified as the cause; refer to codes in the M35.0x series for Sjögren's syndrome with associated ocular manifestations.
• Query the provider for clarification on laterality and underlying etiology if not clearly documented to allow for more specific coding.