ICD-10-CM Billable Code

H02.211

Cicatricial lagophthalmos right upper eyelid

Clinical Classification Guidelines

Medical Intelligence & Overview

Cicatricial lagophthalmos of the right upper eyelid is a condition characterized by the inability to fully close the eyelid on the affected side due to scarring or cicatrix formation. This condition can lead to exposure of the eye's surface, causing irritation, dryness, and potential damage if not properly managed. It is classified under ICD-10 code H02.211, highlighting its specific diagnosis related to scar-induced eyelid paralysis on the right side.

Causes & Symptoms

Clinical Causes: Previous eyelid injuries or trauma that resulted in scarring Surgical procedures involving the eyelid, such as tumor removals or reconstructive surgeries Infections leading to scarring of eyelid tissues Burns affecting the eyelid area Chronic inflammation or dermatological conditions that cause cicatrix formation

Key Symptoms: Incomplete or inability to fully close the right upper eyelid Dryness and irritation of the eye due to exposure Redness and discomfort in the affected eye Sensitivity to light Excessive tearing or watering of the eye Potential corneal damage if exposure persists

Diagnostic & Treatment

Diagnosis Path: Diagnosis involves a thorough eye examination by an ophthalmologist, emphasizing eyelid mobility and scarring assessment. The clinician may perform the following:

Treatment Protocols: Management strategies aim to protect the eye, restore eyelid function, and minimize discomfort. Common approaches 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 H02.211 a billable ICD-10 code?
Yes, H02.211 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report H02.211?
Clinical documentation must specify the nature of Cicatricial lagophthalmos right upper eyelid and any associated comorbidities for accurate reporting.

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