ICD-10-CM Billable Code

H02.213

Cicatricial lagophthalmos right eye, unspecified eyelid

Clinical Classification Guidelines

Medical Intelligence & Overview

Cicatricial lagophthalmos refers to the incomplete closure of the eyelid caused by scarring that restricts its movement. Specifically affecting the right eye in this condition, H02.213 describes a situation where scar tissue prevents the eyelid from fully closing, which may lead to exposure of the eye's surface. The condition often results from previous injuries, surgeries, or infections that cause scarring of the eyelid tissue. Proper management aims to protect the eye from damage and maintain vision health.

Causes & Symptoms

Clinical Causes: Previous trauma or injury to the eyelid Surgical procedures involving the eyelid Infections leading to scarring, such as herpes zoster Chronic inflammatory conditions like conjunctivitis or dermatitis Previous eyelid tumors or malignancies that required removal Congenital eyelid malformations (less common in adults)

Key Symptoms: Inability to fully close the eyelid on the affected side Dryness or irritation of the eye surface Exposure keratopathy (damage to the cornea from exposure) Redness and inflammation around the eye Discomfort or a feeling of grittiness Increased tearing or watery eyes due to reflex tearing

Diagnostic & Treatment

Diagnosis Path: Diagnosis involves a comprehensive eye examination by an ophthalmologist, who will observe eyelid function and look for signs of scarring. Tests may include evaluating eyelid mobility, assessing corneal integrity, and reviewing patient history for previous trauma or surgeries. Additional imaging, such as eyelid photography or ultrasound, may be used if necessary to assess the extent of scarring or structural changes.

Treatment Protocols: Treatment strategies aim to protect the eye and restore eyelid functionality. Options include:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is H02.213 a billable ICD-10 code?
Yes, H02.213 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report H02.213?
Clinical documentation must specify the nature of Cicatricial lagophthalmos right eye, unspecified eyelid and any associated comorbidities for accurate reporting.

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